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I shall finish on this note, given that my hon. Friend tempts me. I represent a constituency that is covered by
the Rotherham district general hospital, which was visited by the famous Gerry Robinson and a BBC crew earlier this year. That was on national television, and my hon. Friend may recall two consultants in the ophthalmic department. One of them would do cataracts only under a general anaesthetic and the other one would do them only under a local anaesthetic. The latter consultant would normally do about six or seven in any one session, and the other would do only three. It is true to say that to some extent the royal colleges might defend that, although the risk of using general anaesthetic is greater than that of using local anaesthetic, but that consultant did not use it because he would not. I thought that that was wholly wrong, and I am pleased to say that he is about to begin a long and happy retirement from the NHS.
Everyone is obliged to keep up to speed with what is happening in their profession, and Members of this House, of all parties, do so all the time. I do not put in my manifesto what I put in it when I stood for election in 1983. I do not say things in this House that I used to say in 1983 either. We all have a duty to ensure that we keep up to speed in many areas, and the medical profession should have as well. I am pleased to have had the opportunity to relate some of my experience, and explain what the GMC feels about some areas of the Bill. It is a great opportunity for us to advance health care in this country, and have health care that looks after patients, the public interest and doctors as well. I am pleased to support the Bill.
6.6 pm
Sandra Gidley (Romsey) (LD): We welcome the broad aims of the Bill, but as always, the devil will be in the detail when we get to Committee. The thought has already been expressed that it is bit of a shame that we are faced with yet another reorganisation. The Healthcare Commission is fairly new, as is the Commission for Social Care Inspection. It would have made more sense to have brought them together three years ago, as the Liberal Democrats suggested at that time. All parties favour a more joined-up approach, but we have to guard against a one-size-fits-all mentality. When we are talking about regulation, we need to remember that what a large acute hospital requires is very different from what might be required when regulating a small domiciliary care agency. Both are important in their own way, but they require different approaches.
It is also worth putting it on record that the existing regulators have done some excellent work in their differing fields. Concerns have already been expressed that the new body should retain a strong focus on social care. There are fears of health domination. I do not know how well founded those fears are, but health issues are much more high profile in the media agenda and sometimes in this place, so we must do all we can to ensure that social care does not become the poor relation.
The CSCI has expressed concern that any additional duties for the care quality commission should be adequately and separately funded, such as any duties that might stem from the current focus on hospital-acquired infections, which are also covered in the Bill. Otherwise, it is feared that resources could be squeezed from social care to fund that health agenda. Although
we all support money being spent on ensuring that our hospitals are clean and safe, that must not come at the expense of the vulnerable and elderly.
The CSCI has been fully committed to paying great attention to the views of those who are—I hate the phrase—service users, and their families and carers. It is essential that we retain that process at all costs. Indeed, the Healthcare Commission has been moving in that direction latterly, but there is little in the Bill to provide assurances that the patient’s voice, or even that of the carer, will be heard. We can learn a lot from those experiences.
The Mental Health Act Commission provides for regular unannounced visits to those detained under the Mental Health Act 2007. The frequency of those visits needs to be protected, because it is a crucial tool in ensuring that the rights of the 45,000 people detained each year are protected. Can the Minister confirm what measures will be put in place to ensure that those standards are not eroded?
It is not clear how the funding will work out, which is causing some concern. The regulatory impact assessment discussed a number of different models, but a wide range of possible costs and savings would apply. We need to be clearer about the detail as we approach the Committee stage. The Royal College of Psychiatrists has raised concerns about some services being squeezed and about whether some of the monitoring and notification work that it undertakes will continue in its present form.
It would be helpful if the CQC could continue the work of the MHAC in reporting admissions, discharges, deaths and other relevant information on behalf of detained patients. Many organisations suggest a rights-based approach and hint that the Bill has missed a bit of a trick. Clause 44 is welcome, in as much as it gives the CQC the facility to conduct special reviews and investigations into health and social care of a certain type or as provided for certain groups. It is important to consider those with learning disabilities, particularly given the recent example of the Cornwall Partnership NHS Trust. Over the years, concerns were raised by families and carers, and if the CSCI’s approach had been taken, those views would perhaps have been taken more seriously earlier. Only when a joint investigation was undertaken by the Healthcare Commission and the CSCI were 64 cases of abuse uncovered that had happened over the past five years. We must remember the background: the trust was given a high star rating while people in its care were abused. We need to ensure through the fine detail of the Bill that such an incident will not happen again. A facility to consider how an organisation treated a group of people with a disability or whether people with a mental health problem were being treated differently would have been welcome.
The Bill provides us with an opportunity to close the human rights loophole. Nine out of 10 care homes are privately owned or in the charitable sector, and so human rights legislation does not extend to them. Attempts were made during the passage of the Equality Act 2006 to try to introduce some legislation on that matter, but the Government resisted. I hope that they will be more sympathetically disposed on this
occasion. Residents of independently run care homes who experience rights abuses cannot challenge their care home provider.
One example of bad treatment that breaches human rights is that of older people in care homes who are told that they have to move to a different home at short notice, which engages article 8 of the European convention on human rights. Other examples often include disputes about care home visitor hours, restrictions on social relationships and even refusal to allow cohabitation with partners in the same care home. Those examples are at one level, and cases of elder abuse that occur on another level in care homes are, thankfully, a minority. Any abuse should be taken seriously, and the individual should have a chance to challenge it.
I turn now to professional regulation. I must declare an interest as a member of the Royal Pharmaceutical Society, which will be no more as a result of the Bill. It is somewhat unusual in that it regulates the pharmacy profession but also acts as a representative body. In the post-Shipman era, we are moving towards councils with a parity between professional and lay members. It is difficult for such a body to represent the profession adequately. The Bill will set up a general pharmaceutical council, which is a move that most in the profession now support. However, there are concerns that the move is being foisted on the profession by the Government. Most of the profession seems to feel that there has been a lack of help in setting up a professional body or something akin to a royal college, as suggested by Lord Carter in the Carter review.
The balance of any health care regulatory council is important. Instinctively, it would seem right that there should at least be a lay majority. That would help the public to have a greater trust in the regulators. There is a perception, whether it is right or wrong—I think that it is wrong—that the professions look after their own. I contend that the opposite is the case. The vast majority of professionals in any health profession do a good job and they do not want rotten apples in the barrel. The professions are quite hard on themselves. As we are always told that an evidence base is needed for introducing any change in regulation and policy, what evidence is there that a lay majority gives a better outcome for patients? I do not think that there is any. Dame Janet Smith and the Shipman inquiry suggested it, but there is no hard evidence that it is better for patients.
More controversial is clause 104, which seeks to reduce the standard of proof for doctors, nurses and midwives and the General Optical Council from the criminal to the civil. Most of the noise has been made by the British Medical Association on behalf of doctors. However, the General Medical Council, also on behalf of doctors, planned to introduce such a measure anyway, as was mentioned by the right hon. Member for Rother Valley (Mr. Barron). I understand the concerns of individual practitioners, who must instinctively feel that if they transgress they are at greater risk of losing their livelihood. That must add stress and worry. Other health care regulators, including those in my profession, have managed the civil standard of proof well. It is a serious step to strike a health professional off the register, and it is not done unless there is an overwhelming balance of evidence. It is not done on the balance of probabilities. People have
to be sure. We also forget that the people who sit on such committees and listen and decide the outcomes are human too. They apply a standard of fairness in such cases.
Although the right hon. Member for Rother Valley welcomed the concept of responsible officers, that measure is not welcomed universally. The responsible officers will be situated in NHS trusts and primary care trusts in England. All practising doctors will be able to relate formally to a responsible officer, who will be responsible for evaluating doctors’ fitness to practise. It is not yet clear where that role will be based. It has been suggested that in a hospital trust, the medical director might be the appropriate person to take it on. However, medical directors already have a heavy work burden and the extent of a responsible officer’s work load is unclear. That needs to be teased out in Committee.
The creation of responsible officers could give greater impetus to resolving problems locally so that they are not necessarily referred up to the GMC. However, conflicts of interest could arise if there were personality differences. Again, we must ensure that the system is seen to be fair in all cases.
I want briefly to mention the general pharmaceutical council, which is being set up to regulate pharmacists and pharmacy technicians and to inspect premises. I want to draw the Minister’s attention to a little bureaucratic overkill. The council will maintain registers of pharmacists, pharmacy technicians and pharmacy premises in Great Britain. That is fine; there is no problem with that. However, the primary care trust also maintains a provider’s list of local pharmacies, with the power to suspend or remove. It appears from the Bill that the care quality commission will require a third form of registration from individuals or companies, with the potential to intervene in the same manner as the other two regulators. That multiple registration creates potential for duplication and confusion, as well as giving rise to additional expense for health care professionals. One registration is enough. I must already pay £400 next year to stay on the pharmaceutical register, and there is debate in the profession about whether that constitutes value for money.
The hon. Member for South Cambridgeshire (Mr. Lansley) mentioned the devolution to PCTs of the global sum for pharmacy services. In theory, that is a good idea because it should enable them to determine the nature of services locally. However, the hon. Gentleman was right to say that there has been a problem with PCTs, which have not commissioned the enhanced services that the pharmacy contract envisaged. In the case of some services, such as pharmacists going into care homes to review medication, the commissioning has decreased since the contract was introduced. Primary care trusts simply do not understand pharmacy or its potential. I therefore ask the Minister whether he will ensure, if the Government are hell bent on introducing the proposal, that proper pharmaceutical expertise in practice-based commissioning is in the right place in the PCT. That will ensure that the money is best used. I make that point not for pharmacists or out of fear that the money might go to GPs instead, but so that we use all the money to patients’ best advantage.
The health in pregnancy grant—a one-off £190 —is a bit of gimmick. The Royal College of Midwives estimates the cost to be more than £120 million, and we
heard a different estimate earlier. However, that assumes that there will be no baby boom. The RCM says that it supports the grant in principle, but asks for reassurance that its introduction will not be at the expense of investment in maternity services. It pointed out that the spend on maternity services fell last year by £55 million.
I felt that child measurement in the Bill was a bit of a tick-box exercise. However, when I looked into the matter, I realised that we have a golden opportunity to do some joined-up thinking. If we get it right, we will have a tool that proves useful for health professionals in identifying early obesity. The earlier we realise that a child is becoming obese, the easier it is to intervene and change the diet. I understand that height and weight will be measured. In themselves, those are fairly meaningless measurements; we should also calculate the body mass index and plot it on a graph. Measuring BMI makes it easier to spot any deviation from the norm and potential weight problems.
However, according to the press release, parents will be sent the height and weight of their child. If they have access to a computer, they can go on the website and discover their child’s BMI. That is pointless because most parents will probably not do it, not everybody has a computer and, most important, there is no tracking. It is important to track the change in BMI. Will the Minister consider the matter and ensure that an opportunity is not squandered in the Bill?
As well as the Bill’s introduction, the Department for Children, Schools and Families will publish its children’s plan in December. The plan is expected to include some thoughts on obesity. The Department of Health will also develop an obesity strategy, although the publication date is unknown, and a new child health promotion is destined for the new year. All those measures will be introduced at almost the same time, and it would be nice to have some joined-up thinking so that we can start to tackle one of the biggest public health challenges that we face.
Much in the Bill is welcome. Some details obviously need to be firmed up, but on the whole, Liberal Democrats support its broad principles.
6.26 pm
Mrs. Joan Humble (Blackpool, North and Fleetwood) (Lab): I am pleased to take part in a debate on a complex Bill that contains many welcome aspects but also raises many questions. I shall ask my hon. Friend the Minister a few questions and I am sure that even more will be asked as the Bill progresses.
I want to speak primarily about the care quality commission but start by welcoming some other elements of the Bill. I am sure that the overwhelming majority of pregnant women will welcome £190—the health in pregnancy grant—whether it is to help them with their diet or, as the explanatory notes state, other aspects of late pregnancy, which could do with some extra money.
Greg Mulholland (Leeds, North-West) (LD):
Surely the genuine concern is about pregnant women’s diet. All the health evidence shows that that must be tackled early in pregnancy or even before pregnancy to have an impact. All the social evidence shows that the most concern is about those on the least income—the most disadvantaged. Why, therefore, are we considering a
one-off payment late in pregnancy rather than extending the healthy start scheme, or doing both?
Mrs. Humble: The hon. Gentleman makes an interesting point, but he is not placing the payment in context. A woman must attend pre-natal classes and engage with doctors and health visitors. I anticipate that, when a woman becomes pregnant and goes to her doctor, she will be advised at that stage—all women are given advice about diet, exercise and looking after themselves in pregnancy—that, if she maintains her links with the health service, she will be entitled, at 29 weeks, to the valuable sum.
Mrs. Humble: I anticipated making only a brief reference to the health in pregnancy grant, but it appears that we must explore the matter. I shall give way first to the hon. Member for Romsey (Sandra Gidley).
Sandra Gidley: It is interesting that the hon. Lady seems to believe that the grant will be linked to attendance at antenatal classes. Antenatal classes in my area have been cut and cut, and there are now not enough for women to attend, so if the grant increases their availability, I shall be delighted.
Mrs. Humble: The explanatory notes refer to seeking medical advice, which I am sure will mean whatever is appropriate in an area.
Mr. Stephen Crabb (Preseli Pembrokeshire) (Con): The hon. Lady is generous in giving way again. She is being rather bold, as her assumption about how the Bill will work in practice goes beyond what it says. There is no requirement for a series of antenatal classes with ongoing advice about nutrition, just a requirement for a one-off meeting for general advice about maternal health.
Mrs. Humble: This is exactly the sort of debate that we need to have. In order to access the grant, the woman will have to seek advice. I hope that that same woman will seek advice at an early stage in her pregnancy, as indeed most women do. They either go to the doctor to confirm that they are pregnant or go to the doctor once they have confirmed that personally. I remind the hon. Gentleman that the grant should be seen in the context of other initiatives from the Government, such as Sure Start projects and the expansion of children’s centres. Women would have to sit at home and not read a single newspaper, not watch any television and not leave their houses in order to avoid all the advice that they are now given not only about their pre-pregnancy diet and diet once they are pregnant, but about having a healthy lifestyle in general. I welcome the grant and I am sure that it will be appreciated by the overwhelming majority of pregnant women.
A second aspect of the Bill that I welcome is the removal of the liable relative rule. It is clearly unjust to require a husband or wife to pay for the cost of the care of their spouse in a care home over and above the resident’s contribution. Indeed, the overwhelming majority
of local authorities do not enforce the rule, so I welcome the fact that we are going to remove it. I also welcome the new public health measures to help to prevent and control the spread of serious disease.
The extension of direct payments to those who lack capacity, by allowing payments to be made to a suitable person who will manage it on their behalf, is a welcome move, especially for families who have severely disabled children. Those children can access direct payments, which are usually made through their parents. When that child becomes 18, they cannot continue with direct payments, because they will then be an adult lacking capacity, but under the proposed extension they will be able to do so. Other groups will also be able to access direct payments for the first time, including people with dementia, people with learning disabilities and people who may have a fluctuating capacity.
Will my hon. Friend the Minister offer an assurance that vulnerable people who lack capacity will be protected? The Mental Capacity Act 2005 sets out a functional test for capacity. An individual might lack the capacity to make certain decisions, such as complex financial decisions, but might well be capable of making decisions about their personal care. In the context of direct payments, an individual with learning disabilities might not be capable of managing their finances, for example, but whoever is doing so should ask them what sort of care they want, in order to determine whether they can talk about the care that they feel they should have. Let us not think that the extension of direct payments means removing all decision making from an individual, because the same individual could, within the terms of the 2005 Act, be more than capable of making some decisions, while being incapable of making complex financial decisions.
I also welcome the transfer of the pharmaceutical global sum to PCTs. PCTs should already be working with pharmacists. Reference has been made in this debate to the new pharmacy contract. I visited my local pharmacy, near where I live in Blackpool, after the new contract was introduced. My local pharmacist had set aside an area for private discussion and consultation. He was looking forward to engaging with his customers and offering them advice. Pharmacists now have a public health role that they should be working to. The transfer of the global sum to PCTs represents an opportunity for them to work much more closely with pharmacies to deliver that important part of the Government’s public health agenda, so I welcome it.
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