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I wish to say something about amendments Nos. 98 and 99 which were tabled by the hon. Member for Sutton and Cheam (Mr. Burstow) and his colleagues. They deal with nurse-led care provided in the home not by an agency, but by the direct supply of a nurse-led service. The hon. Gentleman has done the House a service in raising this issue because a problems needs to be addressed. A well-publicised case in Essex illustrates the problems of a nurse--in that case a nurse in the NHS--working in the homes of individuals. There is a clear need to ensure that nurse-led services are properly regulated.
The Minister may accept the hon. Gentleman's amendments. However, if she chooses not to do so, she must tell the House how the Government envisage regulation of direct nurse-led care. I hope that she will not resort to telling the House that the Secretary of State's powers under clause 42 could be used to widen the scope of the Bill. We take the view that it is not satisfactory, when a Bill is not yet on the statute book, for a Minister to suggest that the use of regulatory powers to extend its scope is an adequate alternative to sending the Bill back in good order to the other place for further consideration.
Mr. Burstow: I rise with encouragement from some Labour Members. I wish to speak briefly to amendment No. 97 and then consider the amendments that were tabled by me and my hon. Friend the Member for Isle of Wight (Dr. Brand).
The Government amendments are all very welcome. They address several concerns that were raised by the hon. Member for Runnymede and Weybridge (Mr. Hammond) in Committee. The hon. Gentleman, in describing amendment No. 97, rightly alighted on another issue that we explored in Committee when we considered clause 100, which also deals with definitions. Through amendments that I and my hon. Friend tabled, we examined the issues relating to definitions. One of the points that came up then was that the definitions of personal care that were in the Bill at that stage called into question whether sheltered accommodation, sheltered housing and extra supported housing schemes would suddenly find themselves bracketed with care homes.
The Minister gave us assurances in Committee that seemed to imply that the only way to deal with the issue was almost to do away with a single definition of personal care and introduce a multiplicity of definitions. That gave me grave cause for concern in terms of the tenor of Government statements about their long-awaited response to the royal commission on long-term care.
Amendments Nos. 98 and 99 return us to a debate that we had in the Committee's third sitting when I and my hon. Friends sought to clarify the definition of medical agencies. The Minister offered reassurances that led us to withdraw two amendments that sought to probe the Government's intentions on that matter. However, we have since consulted further and we feel that there is a gap in the definitions through which some providers may pass, unregistered and unregulated. The hon. Member for Runnymede and Weybridge described a recent case that goes to the heart of the matter.
We are trying to ensure that health care services at home which are not based in clinics or hospitals will be covered by the regulatory framework that the Bill will put in place. Some may be covered by the term "independent medical agency" as defined in clause 2(5), but that definition is inadequate. Although in Committee the Minister assured us that the definition of "nurses agencies" would cover all our concerns, the Bill deals with them only in their role as staffing bureaux, and not as direct health service providers.
Health services provided in the home by nurses without the need for supervision by a doctor can be extremely complex; for example, home blood transfusions and chemotherapy are two of the important services now being provided in that way. Professions allied to medicine, such as occupational therapy and physiotherapy, are understandably and rightly providing services in the home, and they do not appear to be included in the Bill's regulatory framework. None of those examples fits the definitions in the Bill.
A health care staffing agency provides temporary and permanent staff, and there is confusion about that. We hope that the Minister will be able to clear that up in her response. Historically, nursing agencies have provided a mix of health and social care services, and that is why, in the other place, nursing agencies were included in the Bill in an amendment. As things stand, however, it is possible that direct health care provided at home, which is not covered by the provisions on nursing agencies, will be left unregulated. Those services will be covered only if they are provided by a nurse under the control of the patient. We therefore tabled amendments Nos. 98 and 99 to flag up the concerns felt by several people who are involved in providing such services and who are anxious that they will not be covered by the regulatory framework.
Dr. Brand: Does my hon. Friend agree that a good example of such services are those provided by independent midwives? They may well deliberately work without the support of a medical practitioner, and patients' only protection is the opportunity to complain to a regulatory authority, which deals with professional standards rather than the care provided.
Mr. Burstow: My hon. Friend is absolutely right to use independent midwives as an example of the problem that we are flagging up. We hope that the Government will accept that there is cause for concern and that the problem needs to be addressed. As my hon. Friend said, patients' only recourse in respect of such practitioners is through the professional body that registers them.
The Government have accepted that there needs to be one agency for the registration of people, such as social workers, and another separate agency for the regulation and registration of agencies and establishments. We think that the same rule should apply in this case.
Doctors will be regulated by the Bill, but nurses who work on their own will not necessarily be regulated. My hon. Friend gave another example of a practitioner who works alone. Nurses and care assistants do not appear to be caught within the regulatory framework, and professions allied to medicine also appear to be outwith the Bill's scope.
We hope that the Minister will accept that our concern is real and that, even if the precise wording of our amendments is unacceptable to the Government on technical grounds, they will find a vehicle in the other place to enable them to close the loophole.
Ms Stuart: I shall respond first to amendment No. 97, which is intended to ensure that sheltered housing schemes are not required to register as care homes. I am aware that concerns have been raised about whether sheltered housing or supported accommodation will be registrable as a care home, so I want to reassure hon. Members that we do not intend to extend the requirement to register to new types of accommodation that have not previously been regulated.
Clause 3 defines a care home as one providing accommodation together with nursing or personal care for persons who are or have been ill; persons who are disabled or infirm; or persons who are or have been dependent on alcohol or drugs. The Registered Homes Act 1984 included the provision of board within its definition of a residential care home, but the Bill omits it from its definition of a care home, so as to ensure that providers who, to all intents and purposes, run care homes, but are currently able to avoid registration by operating pay-as-you-eat schemes, are required to register.
There is no clear definition of what constitutes sheltered housing and little consistency in the use of the term in the field. I assure the House that it is not the Government's intention to require schemes in which people live in their own homes and receive personal or nursing care to register as care homes. The great majority of such sheltered housing schemes involve care being provided to people in their own homes, and a person's own home, whether that person is a tenant or the owner, will not be registrable as a care home.
Mr. Burstow: I want to check one point. We are dealing with a Government Bill, yet the Minister is telling us that it sets out no clear definition. Surely the Government have it in their power to provide a clear definition?
Ms Stuart: I am grateful for the hon. Gentleman's concern to ensure that we do not make mistakes. I assure him that we shall do everything in our power to ensure that there is no unintentional extension. I can add little to what I have already put on the record in connection with amendment No. 97.
Amendments Nos. 33 and 34 deal with clause 2, which, as currently drafted, contains a provision designed to ensure that independent clinics and independent medical agencies, which are mainly small organisations, are properly regulated, but not over-burdened by regulatory or review bodies. The amendments would change that, and I am surprised that such an approach has been adopted. Clause 2 provides that independent clinics, such as privately run walk-in medi-centres, and independent medical agencies, such as organisations that arrange for doctors to provide call-out services for private patients, will be regulated by the National Care Standards
Clause 2 as it stands draws a clear demarcation of the National Care Standards Commission's role as regards independent clinics and independent medical agencies. Such establishments and undertakings will be regulated by the commission to the extent that they are wholly engaged in providing non-NHS services.