Health and Social Care Bill

My Lords, Amendment 278BA in my name will appear later this afternoon under Clause 71. In view of the discussion so far, however, I think it appropriate that I make my comments now. This is a probing amendment on which I hope the Minister will be able to provide some clarification. The amendment seeks to address the maintenance of quality standards across all qualified providers, be they NHS, private or the voluntary sector, in three key areas. We have heard mention already today about ““any qualified provider”” and this is the area on I wish to spend some time. One of the current issues with private sector contracts is that when serious complications arise, requiring intensive care facilities, the patients invariably end up in the NHS. Continuation of care is essential in all areas but it is particularly important in the area of surgery. The experience of the independent sector treatment centres in the NHS, mentioned by the noble Lord, Lord Rea, and others, has not always been a happy one for the medical profession. If the noble Lord, Lord Warner, who has championed their introduction, was here he would have taken some comfort from the recent report that the noble Lord, Lord Rea, referred to. When I was president of the Royal College of Surgeons I actually instituted a national audit to compare outcomes of care between the NHS treatment centres and the NHS. The Patient Outcomes in Surgery audit was launched in 2007 by the Royal College of Surgeons and the London School of Hygiene and Tropical Medicine. I said at the time: "““This Audit will provide solid evidence as to whether patient outcomes differ between the ISTCs and the NHS. It is imperative that patients receive a sustained, safe and quality service, which is consistent””—" and that is the point, consistent— "““across surgical providers””." The outcome of the audit, published this October, analysed four operations: hip and knee replacements, hernia and varicose vein surgery across both provider types. It found that the outcomes from the ISTCs were equal to or generally better than the NHS where both elective and emergency patients were treated. Again, the noble Lord, Lord Rea, made the point that the NHS deals with emergency patients as well. The report highlighted the fact that the patients treated in these centres were younger, fitter, healthier and less likely to have co-morbidities than their NHS counterparts, making them a lower risk for complications. Jan vanderMeulen, professor of clinical epidemiology at the London School of Hygiene and Tropical Medicine, points out: "““Independent sector treatment centres treat only non-emergency cases. The separation of elective surgical care from emergency services is likely to have a positive impact on the quality of care, irrespective of whether the elective surgery is carried out by a private company or the NHS””." This is something that I believe passionately: the exercise of the ISTCs has demonstrated that if we separate functionally elective from emergency care, we will improve the quality of care for patients, irrespective of whether that is done in the private sector or within the NHS. There is a downside, however, and this was pointed out by Professor Norman Williams, current president of the Royal College of Surgeons, when he warned, "““we need to guard against any drift that could destabilise hospitals. Sicker patients have needs that only a comprehensive hospital can provide””." There is a danger that if you move a lot of care over to ISTCs and so on you may destabilise the acute services in the NHS. Any qualified provider offering a surgical service must adhere to and abide by the same standards as NHS providers. We called for a level playing field in 2007 with respect to ISTCs and it is interesting to note that the noble Lord, Lord Hunt of Kings Heath, who is not in his seat, said in a speech to the NHS Confederation in March 2007: "““We want an even playing field between the NHS and the independent sector. Patients, wherever they are treated, should be assured that the regulation is consistent””." I would echo the words of the noble Lord and ask the Minister to reassure us that there will be a level playing field, not the inequalities which led the Health Select Committee to report on 13 July 2006 that the first wave of ISTCs cost 11 per cent more on average than the equivalent NHS cost and that some ISTCs delivered only 50 per cent of the cases they were contracted to treat. I believe the tariff would address this but I seek assurances none the less. We wish to see the end of cherry-picking and spot-purchasing and a return to a level playing field for all providers. This Bill will help to cement the role of the private sector in surgery but there needs to be regulation by Monitor to ensure that private providers deal with their own complications and do not become a burden on the NHS. The provisions that have been put in place, such as the requirement to treat patients within 30 days of discharge, are a way forward but do not complete the picture. The second area relates to the NHS Outcomes Framework 2011-12 which aims to provide a national-level overview of how well the NHS is performing and to act as a catalyst for driving quality improvement and outcome measurements, some of which I have already referred to in relation to the Patient Outcomes in Surgery audit. Quality standards set by NICE will drive the initiative and must be met by all providers, including the private sector and any qualified providers. This is what I assumed the ““qualified”” part meant. Originally we talked about any ““willing”” provider and we now refer to ““qualified””. As I said, the use of indicators such as the emergency readmission within 28 days of discharge, while an important first step, does not capture non-acute complications like failed hip or knee replacement operations which will require revision surgery. Monitor must have the ability to ensure that all qualified providers adhere to the NHS outcomes framework and this amendment would make that possible. If all qualified providers are required to strive for the goals set out in the outcomes framework, the health of the nation will be improved and this will undoubtedly meet one of the ultimate goals of this Bill. We discussed education and training earlier so I will not go into that in detail. However, it is important to point out that the first wave of ISTCs was contracted without any need to include education and training. Efforts were made to introduce education and training in the second wave of ISTC contracts but I have no evidence that this actually took place. In the private sector this was not an issue when private beds were within the NHS. Junior doctors used to work in private hospitals providing night cover and receiving some training during the day. These arrangements have more or less ceased and there is no structure for formal training in private hospitals, unlike the structures in some hospitals in the United States. As more and more procedures are done in the private sector—currently an estimated 7 per cent of all elective referrals—trainees are losing the valuable opportunity to observe the many different types of procedures and surgery in hospitals. Monitor must be given the power to correct what has been a training deficit by requiring all providers to have a contractual commitment to education and training and to deliver the standards and outcomes agreed and published by the profession. The royal medical colleges stand ready to undertake the quality assurance of training which, in the case of surgery, can only be done by those who have front-line experience in the speciality in question The Prime Minister’s speech last Monday introducing a strategy for UK life sciences highlighted once again the importance and value of translational research and the need to get innovation to the bedside as quickly as possible. The £180 million catalyst fund will help to move medical innovation closer to patients and my amendment would allow Monitor to regulate to encourage all providers to engage and participate in research. The need for equity between the private sector providers and the NHS is pressing. There needs to be a mechanism in place to ensure that any qualified provider, irrespective of the sector, is held to account using the same standards in regards to professional guidelines, education and training, research and the NHS outcomes framework. Amendment 278BA seeks to address this issue and foster debate among noble Lords. I very much hope that the Minister will address some of these points in his response.