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I hope that patients are going to look at the website to see which orthopaedic surgeon they will choose out of those listed for a hospital, or whether they might go to another hospital because it has better outcomes. I certainly hope that that will happen eventually, but this is a start. I support the thrust of the amendments, which suggest that we need to be clear about what we include in the quality accounts that will make the difference to patients, clinicians and the system.

Lord Campbell-Savours: The noble Earl, Lord Howe, referred to hospital-acquired infections. I want to take that a step further. We all welcome the principle, but I want to put forward a scenario. What would happen in those conditions? I presume that in the regulations there will be a requirement to report on cleanliness in wards, because that is a very important issue for patients. I have spent months and months in hospitals, and some of the experiences that I can recall are pretty appalling—the state of the loos in hospitals, to start with.



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Who is actually going to evaluate the state of the cleanliness of a loo on a ward in a hospital? I would have thought that all the hospital mechanisms would say, “Our hospital loos are clean. There are no problems. We hear good reports. The nurses tell us that they’re in good order”, whereas in reality patients often complain about them. It has been going on for years and is still going on. So who will write that report? If someone on a hospital ward complains about the condition of a loo, a ward, a mop under a bed or whatever, a row will break out within the administration about whether it should go into the report or whether it can be blocked. They do not want to see it.

Baroness Murphy: Perhaps I can help the Committee by reminding the noble Lord, Lord Campbell-Savours, that there is now a very good hygiene monitoring system in addition to the hygiene code. People may fall short of the code, but very clear standards are established and they are well monitored and reported on. It is a good example of where, despite the horrors that we know still exist, a system is in place to try to address the problem.

Lord Campbell-Savours: I am aware of the code, but a hospital may choose to hide behind the existence of the code when it is writing its report. It may not wish to volunteer the information that, despite whatever codes exist, it regularly receives reports on a lack of cleanliness in loos and on wards in hospitals.

Baroness Young of Old Scone: Perhaps I can provide some clarification on the new regime on healthcare-acquired infection that will come into place on 1 April. All NHS trusts will be required to register with the Care Quality Commission for their performance on healthcare-acquired infection. We will publish those registrations, including any conditions that we lay on trusts that fail to perform to the code. My understanding is that, as I am sure the noble Lord, Lord Darzi, will confirm, the regulatory performance of individual trusts will be a core part of the quality accounts. It will not be an optional ability to bury their bad news.

Baroness Meacher: Perhaps I may add just one further bit of clarification on this crucial issue—and it is crucial, actually—which relates also to the point raised here about dignity. The fact is that there is now an extremely detailed patient survey: direct responses by patients about their treatment on a whole range of issues. If they are unhappy about the loos, they can make that clear on the patient survey. One of the greatest innovations over the past few years is the introduction of this patient survey. We trusts cannot wriggle out of that; it is all there on paper. You can benchmark across all the trusts and see exactly where you are. There is no way out.

Lord Campbell-Savours: I think that everyone is queuing to reassure me that there will be no problems. My noble friend tells me that she believes that the accounts will contain a reference to this. The question is: will they? I seek my noble friend’s reassurance that they will be there for all to see when the reports are published.



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Baroness Emerton: Perhaps I may speak very briefly to that point and also say one or two other things. Not only are cleanliness and the cleaning of loos addressed in the code of conduct; it is also to do with the accountability and authority within the organisation. Accountability should be clearly spelt out at the delivery end. As an NHS trust chairman, I had a battle when I found that the loos were absolutely filthy. I asked the chief executive whether he had been into a male toilet in a Little Chef. He said, “I hope you haven’t”. I said that I had not, but I had been into some of their ladies’ loos and there was a checklist in each one. It took me six months to get checklists into every loo in that trust. We have them here, too. So there has been movement. Some trusts probably have not moved forward, but it is not beyond the wit of man to do so. It comes back to the issue of accountability and the authority that comes from the board down to the first level.

That brings me to the list, which the noble Earl, Lord Howe, mentioned, from the Royal College of Nursing. I am aware that much work has been done to develop the metrics for measuring some of the quality issues that the Royal College of Nursing has raised. I agree that some things are more difficult to measure. That comes back to the dignity, care and compassion that are absolutely fundamental to the quality of care. I spoke to this at Second Reading. We must be aware of the danger of this becoming a tick-box system that does not take account of accountability at ward level or in the delivery of care in the community right the way through to the authority at board level. What was the problem at Stoke Mandeville and at Tunbridge Wells and Maidstone? The eye was off the ball. The accountability was there, but the authority had not been taken through. That issue is not recognised in the statement.

I take the point made by my noble friend Lord Walton of Detchant about education and training. I know that you can read here that education and training universities are contracted and commissioned through the PCTs, but I have considerable worries about the isolation of the universities. We only have to look back two to three years to the cutbacks in finance and the fall in the workforce. The education and training universities are set apart, and we need them to be in the Bill as very much part of the exercise in quality.

Baroness Masham of Ilton: I support Amendments 34A and 37A. Only yesterday, I read in the Yorkshire Post that Leeds hospitals have been fined many millions of pounds because they have serious infections of MRSA and C. difficile. Also, no one knows better than the noble Lord, Lord Darzi, that safety in operating theatres is vital. I cannot imagine that he cannot include safety. Hospitals have become dangerous places. They should be as safe as possible. This definitely needs to be emphasised.

Lord Walton of Detchant: Clinical audit—the audit of clinical practice and outcomes of treatment—has been a fundamental part of hospital practice for several years and clearly would be taken account of in quality accounts. That should be recorded.



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Lord Darzi of Denham: I was very gratified to hear this debate. It should reassure noble Lords to know that this is the type of debate that I wanted to create in the NHS. If you go out into the NHS, that is what it is talking about at the moment. I said in High Quality Care for All that I wished quality to be the organising principle of the NHS. I wanted to use any lever that I may have to create that debate. It is working here, and I have no doubt that it will work in the NHS, too.

Most noble Lords have expressed concern about what the quality account is. I will try in a fairly long speech—I will go sideways sometimes—to explain what the quality accounts are and how we envisage them improving patient care. I have no doubt that some noble Lords have said in the House that the quality of care that has been provided has not always been central to the discussion of the performance of the NHS or on the agenda of boards that lead NHS organisations. I have sat on a board for 18 months, and at every board meeting most of the discussions have been about the financial health of that organisation and intermittently about where the threats were from neighbouring organisations in relation to services. In the last half hour of these discussions, someone mentioned quality indicators, which were the minimum requirements that the regulator was required to measure. That is not what I see as quality in the NHS; I see the culture of every clinician, organisation and board as very much the driver of quality improvements for the future.

3.15 pm

Some noble Lords asked why we have picked these three domains of quality, as there are seven domains of quality. We have picked safety because we strongly believe that safety is paramount. The noble Lord, Lord Patel, very eloquently referred to that. We also picked effectiveness. Clinicians have always been accustomed to that. The noble Lord, Lord Walton, referred to audits. Historically clinicians measured audits. The third one, which I believe is the most important and which historically we have not had much regard to as clinicians, is patient experience. I am not referring to patient experience as patient satisfaction surveys, as that is a tick-box exercise. It is not uncommon with patient satisfaction surveys not to get that information until about a year down the line. It is meaningless. It rarely gets down to those providing the service learning from that experience. Therefore, we are talking about sophisticated tools in which we will measure patient experience.

What about the other four domains? We need to start walking before we run. Other domains include productivity, cost-effectiveness and value for money, which I have no doubt are extremely important, certainly in the current economic climate. However, this is a good start to defining what quality is.

The next issue is what should be in the quality account. Whichever way you look at it, the regulator in this country has had a huge impact on improving the quality of services. I am not sure how many more weeks there are. The noble Baroness, Lady Young, always reminds me of the number of weeks, but I am sure she will refer to that later. The Care Quality Commission will maintain the wonderful quality improvements that have been introduced throughout

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the system. We have seen many quality improvements by the regulator and, let us not forget, we have also seen many quality improvements on the back of the operating frameworks. Some have described those as targets. Some of the high quality care targets have worked. You just have to look at the mortality rates for cardiovascular disease. We have had a 48 per cent drop in death rates following coronary artery disease.

The Care Quality Commission will measure all the indicators in the system as it stands, which will be part of the quality account that a provider will have to take ownership of and publish. Also, mostly tier 1 operating framework indicators will be in the quality account.

The bit that the Committee may feel is still blurred is the question: “What else?”. It is the “What else?” that excites clinicians. Clinicians come to work not because they think that they are meeting the core standards that the system requires them to achieve but because they want to excel. They are ambitious and really want to push the frontiers in the quality of care that they provide. They are the experts in what they measure. It is not for us sitting in this House to decide what these measures should be as long as the framework is correct. That framework is, as I described, for safety, effectiveness and patient experience.

In my line of practice, a number of well established national and international indicators reflect the quality and effectiveness of the care that I provide. I want to add newer indicators that reflect the experience of the patients receiving care through my team. That is also very important. We should not forget the safety requirements when working in a very complex health environment in which the risks are constantly increasing. The legislation in front of us would create that broad framework. I hope I have reassured the Committee about the good work that the Care Quality Commission and the NHS operating framework have done together.

MRSA and other infection rates were also mentioned. That will be there. That is a must, but that is not what we are discussing here. We want to encourage further quality measures. We must ask why. It is not just an ambition; it is quality improvement, and there is a science behind quality improvement. People measure things not only for the sake of measuring them but for the transparency that comes with that, which is what drives people to improve the services that they provide.

When we come back in the autumn with the secondary legislation, we will debate what will be in the quality account. I remind noble Lords that a component of the quality account will not be discussed in this House. This will be discussed on the front line, where people are delivering those indicators, which could include audits and other parameters. Some noble Lords have suggested—

Baroness Howarth of Breckland: Before the noble Lord moves on, I want to ask a question for clarification so that I really understand this. I did not speak earlier. Is he indicating, as in some areas, that the various groupings will have a self-evaluation within their particular clinical setting—I am more familiar with that in the setting in which I work—which the CQC could measure in its regulatory evaluations? Is that the kind of concept that he means?



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Lord Darzi of Denham: It will definitely include all the comparative information that the Care Quality Commission will be measuring. That is one of the parameters. The Thames Cancer Registry, for example, has a large amount of data and information that most cancer units in the NHS may wish to start taking ownership of and publishing. In the NHS, we collect large amounts of information. It does not have the ownership of the clinicians who are providing the services, and I want to close that loop. That is the purpose of the quality accounts. We need to make that culture thrive, and that is why I am slightly concerned that we should not surround that space area with the words of legislation.

The future will be different. We should also have the opportunity to develop future indicators. I mentioned that we should start walking before we run. That is the purpose of the creation of the National Quality Board. I am delighted to say that with the regulators—Monitor, the CQC, or patient groups or clinicians at a national level—we could develop further indicators in the future that may fall into any of these three categories. They may fall within the category of the regulator or the category of quality improvements. Quality accounts are not only for secondary care providers. We have a lot of quality to measure when it comes to community services and primary care. We know that we are measuring the quality outcome framework in primary care, but there is a hell of a lot more that we can measure when it comes to providers outside and elsewhere.

Research and teaching were brought up by the noble Lord, Lord Walton, and the noble Lord, Lord Patel, asked a Question in the House about this earlier. The noble Earl, Lord Howe, also mentioned it. I agree that there is a very close link between innovation and quality. You can improve quality only if you are innovating. I sympathise, and I declare an interest. It would be reasonable to consult the service, as most of these indicators will be developed with the service. I do not see this process as a top-down approach. I will not just sit down in the department with many of my very bright Civil Service colleagues and decide what the indicators are. We need to consult the service to see whether there are indicators that will reflect innovation, and the uptake by patients of clinical trials may be one of those. We should never underestimate patients’ sources of obtaining knowledge.

One of the challenges that clinicians have is the inaccurate information that patients have when they come to see clinicians as outpatients. Most of that could be through some of the PR blurb to which the noble Baroness, Lady Murphy, referred. We want to be open and transparent to empower our patients in future, because most of us in this Room have exercised informed choice and that is where we need to head. I hope that I have reassured the noble Lord—

Lord Campbell-Savours: I am not a professional in this area, but a consumer of services. My noble friend referred to MRSA. I could produce data on a hospital from these accounts that would not indicate to the public what is going on. Let us take a hospital with 20 wards. One ward is the principal ward where there is a problem with MRSA. If there is reference in these accounts to the whole hospital, the public is no wiser.

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They need to know which ward. I know that it is difficult for many hospitals to provide that information because they believe that those wards then become vulnerable, but that is the only way to impose the disciplines on those wards to get higher standards. Will the MRSA data be collected across the whole unit or will they be localised so that the public can see what is going on?

On the question of patient experience, I have been a day patient. Even today, I have been a day patient. I seem to be in and out all the time, although I have not been a residential patient for some 12 months. When these patient experience information-requesting arrangements are made and the forms go out are we asking patients who may well be very low, just want to go home and not want to be bothered or is some other arrangement now in place for acquiring that information? If it is based on people who are down and not feeling too good completing forms, I do not think they are going to fill them in very honestly. I certainly would not.

Lord Darzi of Denham: I am grateful for that intervention from my noble friend. I have no doubt that the noble Baroness, Lady Young, will have a lot to say about this as it is in the domain of the regulator. As to which ward has MRSA, every organisation has a legally accountable board. We are trying to get the board to be accountable not only for the whole place but also for every ward providing services and to act upon that information. I have no doubt it is within the domain of the regulator to ensure that boards are held accountable. If the regulator feels that transparency should go down to every ward, that is an issue that it will have to discuss with the board.

Lord Campbell-Savours: It that not also a matter of policy? Surely, the Government must have a view on whether that is right. In representing the public interest in these matters, the Government must have a view about whether that information is available. Whenever I go into hospital, I would like to know which ward is difficult so that I can make a decision about whether I want to go into it, particularly if it is an orthopaedic ward.

Lord Darzi of Denham: That may have been Aneurin Bevan’s vision when he said that the echo of a bedpan falling in Wales would be heard in Whitehall. I see the NHS having that accountability at a local level in years to come. I sympathise with what has been said. I can even go further and say what is happening, certainly with some of the suggestions from another regulator, Monitor, about developing the service line reporting to get that information-based service. The noble Lord could get that information on orthopaedics and figure out where the orthopaedic wards are rather than basing it on wards. We want to measure services. The experience, effectiveness and safety should be around either a disease entity or a speciality interest. That has been successful in certain lines; for example, in cardiovascular mortality rates with the transparency of reporting of mortality following coronary artery bypass graft. We have seen that before.



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Amendments 33 and 36, tabled by the noble Earl, Lord Howe, and the noble Baroness, Lady Cumberlege, appear to open up the scope of quality accounts to include any information that can be published. I appreciate that the noble Earl wishes to see NHS healthcare providers given as wide a latitude as possible in drawing up the accounts—I share that aim—but my slight concern as we try to focus on quality is, for example, that we do not want financial accounts to be part of quality accounts. I would like to keep them within the framework of safety, effectiveness and patient experience.

3.30 pm

Baroness Barker: Perhaps the noble Lord could expand on why. He will be aware that the issue of private provider involvement in the NHS and comparisons between private providers is something that crops up quite frequently. I am interested to know why he wants to separate quality from cost and why, in the longer term, that is advantageous for the NHS.

Lord Darzi of Denham: I have already said that there are other domains in quality and that value for money is an important domain. We are starting here and, initially, within the quality cadre, we want to focus purely on the safety and experience parameters and then expand that to effectiveness. I agree with that. I just do not want a mixture of financial account and quality account with some other parameters that will diffuse or contaminate—if I can use that word—the purpose of the quality account as I see it and as it has been developed from the bottom up.

I hope I have reassured the noble Lord, Lord Patel, that safety is part of the quality definition. As I have described in the Bill, safety is one of the domains. I am very grateful to him for his contribution and to the National Patient Safety Agency for taking on some of the outputs of High Quality Care for All. A few have already been mentioned, such as the never events, which we see as part of quality improvement, rather than the quality accounts, and the reference to the checklist.

I turn to the point raised on the amendment tabled by the noble Baroness, Lady Greengross, which referred to the address by the noble Baroness, Lady Barker, on dignity and respect. That absolutely should not be an indicator because it is not something you can measure; that is part of the patient experience. There are ways in which one can measure that and it is not ticking the box while the patient is asleep or in bed receiving a treatment. Compassion and dignity—the way in which the patient has been cared for—are two indicators that are very much a part of the patient experience domain of quality improvement.

I hope I have reassured the Committee and explained what the quality accounts are. I hope, with that reassurance, that the amendments will be withdrawn.

Earl Howe: I felt sure that we would be treated to an impressive and illuminating speech from the Minister in response to this amendment and so it has proved. For that, I thank him on behalf of the Committee. This has been an extremely good debate. However,

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I am left with one main question mark on a point to which many of us have returned: the burdens, which may, in practice, be placed on organisations. The Minister has indicated that this issue is live in the minds of many in the health service at the moment, and I am glad of that.

However, another area I wanted to touch on was private-sector healthcare providers—particularly pharmacies, which have not been mentioned much so far. The Bill’s impact assessment anticipates the cost of data collection for quality accounts being zero. That prediction may be premature for pharmacies. Until they and we know precisely what the make-up of a quality account will be, we cannot tell whether the information currently collated in pharmacies is in the format in which it will need to be reported.

As it is, the impact assessment estimates that the cost of analysis by a member of staff to produce the quality account in any given organisation will be between half a week and five weeks. The estimate that I have seen is that this will place a cost on the pharmacy market in England of around £20 million a year. That is a significant regulatory burden, and we must find ways of minimising it in a manner consistent with achieving the aims that the noble Lord has in mind.


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