Health and Social Care Bill

My Lords, I shall speak to several amendments to which I have put my name, but I shall start with the amendment of the noble Baroness, Lady Cumberlege, to which I have also put my name. The noble Baroness is well placed to talk about maternity services. She has championed their cause, particularly regarding choice, for nearly two decades. It is she who should be credited for getting us to where we are now, whereby choice of where to have their babies is available to all would-be mothers. The noble Baroness covered most points, and I support them all. The one on which I should like to expand relates to maternity networks. It appears that both the Prime Minister and the Department of Health have accepted that maternity networks are the way to improve maternity services, and I agree. Maternity networks have the potential to increase clinician involvement and service-user engagement in the planning, delivery and, where necessary, reorganisation of services. They also have the advantage of being able to scrutinise the performance and outcomes of all maternity providers within the network, thereby helping to drive up standards and reduce unwarranted variations in outcomes. This will help to develop shared services across the network. Thus a home birth service provided by a modern maternity unit could be made available to maternity units in areas where the home birth rate is very low. I know that a current review of clinical networks is being undertaken for the Commissioning Board, and is due to report soon. Perhaps the noble Earl can tell us more about it. I hope that the review recommends that maternity networks be established to cover all maternity services in England. The concern is that if providers are expected to self-fund networks, there is a risk that some providers, especially foundation trusts, will not engage in networks, thereby reducing their effectiveness. For this reason, I hope that the Government will accept the case for providing some funding and support for maternity networks in the same way as neonatal networks and cancer networks have been able to access central funding and support. One other issue that will improve the quality of maternity services, no matter where that care is delivered, is the establishment of maternity dashboards. They are a good way of auditing the outcomes on a daily basis and establishing whether the clinical guidelines have been achieved. I therefore strongly support the noble Baroness’s amendment. The amendment in the name of the noble Lords, Lord Newton of Braintree and Lord Butler of Brockwell, is saying ““comply or explain””, whereby if you do not comply with NICE guidelines you must explain why. I agree. Not all standards should be complied with, because there may be reasons why they are not. If you do not comply, you have to explain why. However, you also have to explain why the outcome for patients will be the same or better, because if the outcomes through not complying are not the same or better, you should not be allowed to fail to comply. I understand that there might be good reasons why certain NHS bodies do not comply. Another way could be the establishment of an alternative compliance system in which organisations and clinicians are required to justify why they have not complied with the standards or, for that matter, innovations that will aid delivery of the best clinical practice. The Commissioning Board, in conjunction with senates and by way of patient pathways, could develop a compliance regime that measures, monitors and incentivises the use of innovation or compliance where these will improve standards of care. So I support the proposal, and I know that we might return later to the issue that my noble friend Lord Walton raised about innovation, tariffs and the innovation tariff. That is the other side of the coin regarding non-compliance and going beyond the standard of care laid down by NICE. I also support Amendment 110A, tabled by the noble Baroness, Lady Thornton, which states that in discharging its duty, "““in relation to specialised services, the Board must exercise its functions in accordance with current NICE guidance””." This amendment is related to that tabled by the noble Lord, Lord Newton, and I would cite in relation to it the specific example of rare diseases. The amendment seeks to ensure the adoption of clinical guidelines developed at a national level, a point which applies particularly to rare diseases. I would cite the example of treatment for brain tumours and other cancers of the central nervous system, which is commissioned nationally through specialised commissioning, which is due to become part of the NHS Commissioning Board. Rare diseases are currently defined by the specialised services national definition set—which is commonly known as SSNDS. In the case of brain and CNS tumours, the specialised cancer services definition explicitly cites NICE’s brain and CNS improving outcomes guidance as its reference. I am concerned that some elements of the current framework for the treatment of rare diseases will be jettisoned in the name of streamlining. The danger then is that the link between NICE guidance and commissioning formulas used by the board will be broken. This could undermine the quality of services provided by the board to take care of people with rare diseases unless we insist that the national Commissioning Board must adopt NICE standards and that the choice of ““comply or not comply”” is not available for rare diseases. It is a completely different argument to the generic one put forward by the noble Lord, Lord Newton. We could have a discussion about that but my view is that a different kind of compliance is required for rare diseases. I come to my Amendments 144 and 145, which relate to information provided by the health service on the safety of services, which is dealt with in proposed new Section 13Q on page 20 of the Bill. I wish to talk about how learning from information related to patient safety should be available to all NHS organisations; forgive me if I take a couple of moments on this. Before I start, I should like to pay tribute to two remarkable ladies who established and for two years ran Patient Safety First in England: Vin McLoughlin, who died at the age of 55 of pancreatic cancer; and Karen Woo, a young doctor qualified at University College, London, and fellow of the Royal College of Surgeons, who was in charge of safety procedures and developing surgical safety. Karen was killed on one of her visits to Badakhshan in Afghanistan with nine other members of her medical team. I pay tribute to these two remarkable ladies who promoted patient safety in England. Many of the successes, particularly in surgical safety, are due to them. Patient safety is a global problem. On average, around 10 per cent of admissions to hospitals worldwide are associated with some sort of unintended harm to patients. The World Health Organisation set a global challenge for member organisations to improve their patient safety. In the past the Minister has said that the Government give patient safety high priority and wish to see it embedded in all aspects of NHS care, and I believe it. Over the past decade, our understanding has grown. It is now seen as a core focus for many in healthcare, but there are barriers. The barriers are: variable leadership at board level and among clinicians and managers; a blame culture that drives problems underground; defensive communication; limited patient safety education; not enough emphasis on building high-performing front-line teams; and a superficial approach to incident investigation which often fails to identify the underlying causes and system weaknesses. Most of these errors are system weaknesses. Even today there are up to 3,000 reports daily to the NPSA in England and Wales. Most of the incidents do not result in any harm, but 1 per cent are reported as causing severe harm, which is often permanent, and less than 1 per cent are reported as causing death. The reporting and learning system, which I know that the Government intend to set up as part of the national Commissioning Board, uses national data to detect and understand sources of risk by spotting clusters of incidents arising from individual reports that are not often identified until data are analysed at a national level; identifying the most urgent risks by reviewing all serious incidents and deaths and providing extra points; alerting the NHS to potential for harm quickly by providing recommendations, advice and guidance to ensure that the right information gets to the right person; extracting learning by identifying key trends and patterns in incident reports and providing analysed feedback. The work of the patient safety division of the NHS Commissioning Board, as it would be, relating to reporting and learning from serious patient safety incidents will be crucial, but as the Bill states: "““The Board must make information collected by virtue of subsection (1), and any other information obtained by analysing it””—" in relation to safety— "““available to such persons as the Board considers appropriate””." My amendment states that it should be available not as the board considers appropriate but available to all NHS bodies and the public. That is the only way that we can embed learning that might come from one part of the NHS into all parts of the NHS and reduce the harm. I could give examples, such as the establishment of surgical checklists, which has reduced damage and errors relating to surgery many times over; the incidence of intravenous-related infection and central venous line infections; infection rates in neonatal care; and many others. The key messages are that both senior managers and senior clinicians need to demonstrate that patient safety is their top priority. They will do so if they are obliged to report all incidents and take note of the learning that comes from the national learning and reporting system. I hope that the Minister will accept that the amendment is apt. If he can convince me that without it in the Bill, we can achieve the same, I would be grateful.