Health and Social Care Bill

My Lords, I am grateful to the noble Lord, Lord Patel, and other noble Lords for introducing this group of amendments. I agree with the noble Lord, Lord Hunt, that this has been an excellent debate with a shared commitment to ensuring that quality sits at the heart of the Bill. I find that heartening. I recognise the long experience of the noble Lord, Lord Patel, in defining what quality looks like. The grouping revolves around the definition of the duty of quality and how the term ““quality”” is addressed throughout the Bill. As was discussed in earlier debates, the duty of quality enshrined in the Bill is derived from the report of the noble Lord, Lord Darzi, High Quality Care for All, published in 2008. The noble Lord set out that quality could truly happen only when three different factors were present: safety, effectiveness and patient experience. That definition was widely welcomed at the time and over the past three years has become valued across the NHS. The definition did not come out of the blue. The noble Lord’s review was produced with the NHS, with patients, clinicians and managers, using the strategic visions developed in each of the 10 strategic health authorities. Its definition of quality—effectiveness, experience, safety—has survived even the electoral cycle. Indeed, one of our first priorities as a Government when we came to power was to build on the noble Lord’s work. We did this through publishing a consultation paper and then following it up with the first NHS outcomes framework, published in December last year. Respondents to the consultation on the outcomes framework were highly supportive of the continued use of the definition of quality and the fact that the framework sought to measure patient-reported outcomes and patient experience as well as clinical outcomes. The question we have to ask ourselves about the amendments is simple: does the definition need to change? My view is clear: we should stick with the original definition. However well intentioned the amendments are, there would be risks attached to them. I shall start with Amendments 19, 110, 134, 179 and 181. The intention, if I understand it correctly, is to specify that the duty of quality should be restricted to clinical matters in order to ensure a focus on clinical quality and outcomes for patients. I understand the noble Lord’s arguments but my fear is that these amendments would have the effect of narrowing the duty of quality and losing the integrated approach that it embodies. Let us consider this with regard to quality standards, covered in Clause 231. Quality standards, as I have already said, bring clarity to quality, providing definitive and authoritative statements of high quality care that are based on the evidence of what works best. That idea opens up the opportunity for quality standards to cover an integrated care package, from public health interventions in primary care to rehabilitation and long-term support in social care, thereby supporting the integration of health and social care services. I fear that we would lose this integrated approach if we were to restrict the Secretary of State’s obligation to looking only at clinical standards. Similarly, restricting the NHS Commissioning Board’s integration duty to services provided in a clinically integrated way would preclude integration where the board considers that it would be beneficial, although not clinically, to the people receiving those services, such as in improving the patient’s experience. I was very grateful to my noble friend Lady Barker in this context. Focusing just on clinical outcomes would mean the exclusion of non-clinical outcomes, such as access, reduction in health inequalities, healthy living, health promotion and the health-related services that we want to see integrated in an increasingly effective way. In a similar vein, I am afraid I am unable to accept Amendment 15, tabled by the noble Lords, Lord Patel and Lord Kakkar. Clause 2 is clear that the only outcomes that can be pursued relate to the definition of quality. By limiting the pursuit of better outcomes just to health outcomes, the amendment would cut out crucial outcomes such as delivering a better patient experience. We need to look at care in the fullest sense when looking at ways to improve integrated care. I cannot help but feel that these amendments risk undermining this principle. Therefore, I hope the noble Lords will think again about them. Amendment 107 contains a noble sentiment with which I completely agree; the NHS Commissioning Board should focus on delivering better outcomes for patients. However, I hope to reassure the noble Lords, Lord Warner and Lord Patel, that the clause covers this. The outcomes sought in subsection (3) are those specified in subsection (2), which are patients’ outcomes. Amendments 16A and 109 again seek to alter the definition of quality, originally set out by the noble Lord, Lord Darzi, this time in a slightly different manner. The aim of Amendment 16A, tabled by the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt, is clear; it is to emphasise the critical importance of efficiency in the NHS. I reassure the noble Lord that the importance of efficiency is well tackled elsewhere in the Bill. Under Clause 20, in new Section 13D, and Clause 23, in new Section 14P, the NHS Commissioning Board and clinical commissioning groups respectively come under a duty to exercise their functions ““effectively, efficiently and economically””. In this context, ““effectiveness”” relates to the overall effectiveness of the organisation, rather than to the effectiveness of the outcomes that both organisations must pursue in relation to their own duties to improve quality continuously. Therefore, I hope the noble Lord will recognise that the sentiment behind the amendment is already well covered by the Bill, and that he will be prepared to withdraw the amendment. Amendment 109 seeks to amend the NHS Commissioning Board’s duty in relation to quality under new Section 13E, in Clause 20, to include reference to ““timely access to services””. The noble Lord, Lord Warner, may be pleased to know that I do not disagree with a lot of what he said about access. It is intimately bound up with the definition of quality. It matters to patients and can be a good way of predicting good outcomes. Timely access to services encompasses all three of the domains of quality. It is important that patients have timely access to services to ensure the clinical effectiveness of treatment. For example, where cancer is suspected, patients should see a specialist within two weeks of an urgent GP referral. Waiting times remain low and we continue to place an emphasis on this in the operating framework. It is true that without timely access to healthcare you cannot have quality. It is intimately connected with delivering better outcomes for patients, better clinical effectiveness outcomes, better patient experience outcomes, and better safety outcomes. However, while I acknowledge all that, I believe that this all-encompassing definition of quality, combined with the rights that patients continue to have under the NHS constitution on access, makes this amendment unnecessary, and I therefore hope that the noble Lord will feel comfortable in not pressing it. Lastly, I turn to Amendment 18B, tabled by the noble Baroness, Lady Bakewell. She makes an important point that in pursuing improved outcomes there should be no discrimination on grounds of age. Once again, I could not agree more with the intention and sentiment behind this amendment. None the less, I believe it to be unnecessary. First, the Bill places the Secretary of State, the NHS Commissioning Board and clinical commissioning groups under a duty to have regard to the need to reduce health inequalities between the people of England—the first time that we have had such a duty in statute. It is a landmark provision for a broad duty that encompasses all groups in society. Secondly, as we discussed in the previous group of amendments, the public sector equality duty at Section 149 of the Equality Act 2010 requires all public bodies to consider the impact of policies and decisions on particular groups across the ““protected characteristics””—a term of art in the Act—that include age. This general public sector equality duty came into force in April this year. The noble Baroness mentioned that data are not available to measure outcomes for particular groups such as the elderly. I fully agree about the importance of having good data to drive improvement, but data for the over-75s are particularly difficult to collect. Mortality causes in this group are hard to pinpoint, which is why such data are of somewhat limited value as an accountability measure. The outcomes framework is designed to make services accountable. However, older people’s experiences and safety measures are included, and these indicators will of course improve over time. That is our stated ambition. The noble Lord, Lord Hunt, asked me about NICE—