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7.4 pm
David Taylor (North-West Leicestershire) (Lab/Co-op): I want to speak about the establishment of citizens councils for the regulation of health care professionals.
Anyone who reads the Bill will recognise immediately the difficulty experienced routinely by members of the public who seek to decode important issues requiring public scrutiny and debate, and the parts relating to the long-overdue modernisation of professional regulation are no exception. It is that small yet significant part of the Bill that I want to discuss. The co-operative movement, of which I am a tiny part, is perpetually renewed in each generation when aspects of it become more relevant to current issues and dilemmas. Our task is to put it in a contemporary context, which is what I have done in early-day motion 386, tabled today, concerning the establishment of citizens councils for the regulation of health care professionals.
Co-operation and partnership working between citizens and professionals is even more essential in health care today if we are to regain the trust and confidence of the electorate and service users, and their belief that the decisions made give them the rights,
dignity and patient safety that they deserve. I extend the famous Putney debate principle that
“The poorest he that is in England hath a life to live as the greatest he”
to the context of devolution, and the importance of achieving an effective United Kingdom-wide system ensuring patient safety and the best possible patient experience across the 2 million people working in the health care sector.
I do not know whether Members saw an edition of the Daily Mail, published in February 2006, whose front-page headline read “Sentenced to die by arrogance”. It reported that 18 patients had been wrongly given a breast cancer screening all-clear by a consultant radiologist, who had continued to work for 18 months before the employer launched an investigation. The case was then referred to the General Medical Council.
The allegations will sound familiar: a practitioner working in isolation, absence of monitoring of work practice, colleagues not speaking up strongly, and a health trust reluctant to intervene. The public are also familiar with recent cases in which patients have been abused and died. Failures of paediatric surgery in Bristol, and the conviction of GP Harold Shipman for murder, provoked high-profile and expensive Government-sponsored inquiries.
However, this is not just about doctors. Nurses and midwives, dentists, pharmacists and many more have their own regulatory bodies, and the Health Professions Council regulates as many as 13 professions, with more in the queue. Nor—as we have heard in today’s debate—is professional regulation concerned solely with striking people off registers and barring them from further practice. The nine statutory professional bodies are responsible for setting the standards that practitioners must meet in their education and daily practice.
We must ask ourselves what patient and public involvement can add to regulation. If regulation is to be undertaken in the public interest, it must also require public involvement. The regulation of professionals, argued Sir Ian Kennedy in his 2001 report “Learning from Bristol”, is too important to be left to the professions. He said:
“The public are entitled to be involved at all levels and stages: in both setting and agreeing the systems for assuring competence and in their operation.”
The report went on to explain why that should be so:
“First, the public can participate in the process of setting and reviewing the criteria for admission to the profession.... After all, the professional is going to be caring for the public as patients.
Secondly, public participation in this process serves as a warranty that the public's interests are being safeguarded and as a reminder that the profession exists for the public”.
In 1999, the National Consumer Council took an outsider’s look at professional regulation, questioning whether it was fit for the fundamental purpose of protecting the public. It found a confusing patchwork of procedures, terminology and standards for the different professions, and pronounced the system to be out of touch with the times. The Bill gives us a once-in-a-generation opportunity to modernise professional health care regulation for the benefit of future generations.
The challenges that patient and public groups have raised about the direction of change—system complexity, the lack of transparency and clarity in processes, and
the failure to join up complaints and redress systems—remain with us, and measures in the Bill are intended to address those issues. However, the modernisation of professional health care regulation requires a much more dynamic approach to public and patient engagement than is set out in paragraphs 1.11 to 1.27 of “Trust, Assurance and Safety—The Regulation of Health Professionals in the 21st Century” and in the Bill.
The general public do not necessarily know much about regulation, but they assume wrongly—and fondly, perhaps—that there are robust systems for ensuring that practitioners are competent and up to date. That is a reasonable expectation, which Government must ensure is met. In 2005, the Department of Health commissioned a research study from MORI to examine the attitudes of the general public and doctors towards medical regulation and assessment. The key findings of the research are worth highlighting. It was found that few members of the general public know anything about the current system of assessment of doctors after qualification. Almost half of the sample of the general public assume that regular assessments are already taking place, with more than one in five thinking they already happen annually.
There is widespread support for regular assessment among both the general public and doctors. Nine in 10 members of the public and more than seven in 10 doctors thought it important that doctors’ competence be assessed every few years. Nearly half of the public thought that those assessments should be done on an annual basis, while doctors favoured doing it less frequently; interestingly however, hospital doctors seem to favour more frequent assessments than their colleagues in general practice.
The current system of medical regulation is not visible to the general public. It is striking that many people believe that regular assessment of doctors is already taking place. Moreover, almost all wished it to take place frequently, and half said that there should be annual checks. That public view is in marked contrast to that of commentators and politicians, who often hold that regulation should be a “light-touch” process—a view not necessarily shared by patients in the United Kingdom.
Changing traditional professional attitudes requires an informed public, who have an important part to play in co-producing public safety and improving the overall patient experience. That cannot be effectively achieved by the separate PPI—patient and public involvement—arrangements financed by different regulators within the health care team. I hope that the Minister will respond to the fact that the Bill proposes that lay membership of the Council for Healthcare Regulatory Excellence be reduced from 10 to seven people and be appointed to “reflect”—whatever that might mean—rather than to represent, an increasingly diverse public.
The CHRE, which is in practice more accountable to Government than to Parliament, would in my view greatly benefit from independent citizens councils that are representative of, and accountable to, diverse community interests in each part of the UK. I have today tabled early-day motion 386 because we need to recognise the difficulties that patient and public groups face in finding the resources to engage in detail with the complex and intricate processes of balancing professional and public interests. New citizens councils should be
established in each of the four countries of the UK to work alongside the CHRE. The essence of democracy is that it makes it possible—I emphasise the word “possible”—for a diverse public and patient view to express itself.
The citizens council idea is not new. As specified in the English NHS plan in 2000, the National Institute for Health and Clinical Excellence has valued its citizens’ council and has referred to it in positive terms on numerous occasions. There is learning to be had and examples of how it might work in the many citizens juries that have met, and in the national debates that have been conducted in fields such as health, environmental issues, urban planning and genetically modified foods. In the context of health care professional regulation, citizens councils should be independent—and should be seen to be independent—and should be funded from the public purse, in order to explain to, and inform, interested and diverse patient and public groups about the nature and significance of proposed changes to the system of professional health care regulation, carry out consultations and collate responses on a four-country-wide basis.
I stress the importance of lifting this debate out of the technical language in which the dialogue is currently conducted. We should give a real chance for a public perspective to be heard and taken into account, alongside that of the very well-organised and well-financed professions that are constantly lobbying and fully engaged in promoting substantial legislative change, both in terms of this Bill and, as my right hon. Friend the Member for Rother Valley (Mr. Barron) mentioned, through section 60 orders under the Health Act 1999. I believe that one has been tabled today.
Let me finally turn to the subject of health care support workers. There is concern that pressing issues for patients and the public—such as the effective regulation of those who give hands-on care to vulnerable population groups in hospitals, nursing and residential homes and in the community, often involving intimate and personal care in health-care assistant roles—are not being treated with the urgency that they deserve, although such workers are increasingly important in the context of community-based provision.
Those concerns include the lack of education and training for tasks traditionally carried out by qualified, registered health care professionals and the lack of a regulatory framework for health care support workers. Responsibility and accountability for their actions in clinical and other settings cannot continue to be considered behind closed doors, and active public engagement is required. Citizens councils provide the mechanism to make this a reality. I hope that the Minister will respond specifically to that point.
There is common ground among the main political parties; I hear that there is unlikely to be a Division tonight. We are all seeking to find ways of securing democratic renewal and engaging citizens in hard decisions, addressing risks, balancing rights and deciding on priorities for Government action at UK and devolved levels. Although they are invisible to the public—we must ask why—professional health care regulation and the regulation of health care support workers are key areas in which it could be demonstrated that bodies such as citizens councils can work and make a difference. However, the Government also need, jointly, to put in
place a structured system, which is inclusive and ensures that a wider perspective is brought to the debate, alongside the CHRE’s inevitably close working relationship with professional health care regulatory bodies.
The Minister needs no sympathy from me, but it is true that Ministers have an unenviable task in this respect. They have to cope with the intricacies of separate legislation and the complexity of a UK-wide system. They will face—they are already facing—strong professional lobbying, and objections to ending elected member representation will undoubtedly be one theme. Another theme has been the standard of proof in fitness to practise proceedings under part 2 of the Bill. At its heart, however, the issue they face is very simple. The public expectation of health professional regulation is that it will deliver health professionals who can be trusted to provide up-to-date relevant treatment and therapies, who are dedicated to developing their knowledge base, and who have patient safety as their overriding objective.
When things go wrong, people expect a full explanation, and perhaps recompense, but more often changes that will reassure them that the situation is unlikely to occur again. Root-and-branch reform was the demand from some of the patient-focused organisations that responded to the White Paper consultation. The MORI polls that I mentioned earlier showed that people assume that regular checks on health professionals are already in place, and that policy is much further along that road than it actually is. Failure to take decisive action now threatens to destroy public confidence, not only in regulation, but also in the policy process itself.
In summary, public engagement can help drive the co-production of modernised professional health care regulation, especially in relation to secondary legislation, in the period to 2011. I urge the Minister to take on board my comments, and I hope that the Government will introduce citizens councils, so as independently to inform the CHRE’s strategic decision making and strengthen a four-country approach to patient safety and improvement of the overall patient—or service-user—experience.
7.18 pm
Mr. Stephen Crabb (Preseli Pembrokeshire) (Con): It has been a privilege to attend the debate. There have been numerous thoughtful contributions from experienced and knowledgeable Members, and it is a pleasure to follow them.
As suggested by my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) in his response to the Secretary of State’s address, one could have been forgiven for thinking that the first health Bill under a new Labour Prime Minister would be a bold attempt to set a groundbreaking agenda for the health service—that most iconic yet troubled of our public services. In recent months, we have heard some expansive, and at times not unattractive, rhetoric from Health Ministers about tackling health inequalities and the importance of the public health agenda, but I am afraid that the measures in the Bill do not back up that rhetoric and provide little confidence to suggest that the Prime Minister and his Ministers have a serious and compelling long-term vision for our health services.
There is considerable agreement in all parts of the House on the Bill’s broad policy objectives, but I want to address an issue on which there is room for some contention—indeed, it has been commented on already today—the health in pregnancy grant. The notion that pregnant mothers might need assistance in making choices about their diet and lifestyle in order to give their babies the very best start in life is absolutely unobjectionable. In an age of increasing obesity, and yet a wider and deeper knowledge about the importance of good diet in pregnancy, no one would disagree with recognising that the state can play a positive role in supporting pregnant women and helping them to eat the very best food. It is, Mr. Deputy Speaker, literally motherhood and apple pie.
However, it is a huge leap from that position to supporting a one-off cash payment being made to all mothers, regardless of socio-economic background or geographical location—there are differences in health outcomes and diet that are related to the geography of the UK—at a fairly late stage in their pregnancy. It is a huge leap from endorsing the general principle of supporting pregnant women in making healthy lifestyle choices, to supporting a one-off cash payment at a late stage.
Dr. Stoate: I understand the hon. Gentleman’s reservations about the late payment of a one-off grant, but can he come up with a scheme that would work better and really get to all such women, regardless of their circumstances, and not just those who apply for a grant, in order to ensure the widest possible uptake?
Mr. Crabb: I will go into this issue in a little more detail shortly, but where is the evidence to suggest that absolutely all women need assistance from the state in making good choices about their diet and lifestyle in pregnancy? Surely the priority should be targeting limited resources on those in most need. The evidence to suggest that such a crude, untargeted payment after the 25th week of pregnancy will lead to better dietary choices on the part of mothers, and therefore to better health outcomes for babies, is simply non-existent.
Greg Mulholland: Perhaps I can help the hon. Gentleman by asking whether he agrees that we should have strict conditionality regarding what this enormous sum of money is spent on, to ensure that it is spent on what it is supposed to be spent on.
Mr. Crabb: We can look at conditionality, and at alternatives to how this money might be spent that achieve similar outcomes. Where are the results of the pilot and the pathfinder studies to back up these policy proposals? Were any lessons drawn from international experience to suggest that such a one-off lump sum payment can deliver the policy objectives that we want to see?
Mr. Barron: Is there not clear evidence that universal state benefits get to people, and that those that have to be applied for do not?
Mr. Crabb: I am not disagreeing with that—there is no doubt that the cash will get to people. My argument concerns how the cash will be used and whether it will actually deliver the health outcomes that Ministers are saying it will.
I turn to the timing issue and why there is this focus on such a late stage of pregnancy—the 25th week. That approach conflicts with a lot of expert opinion and practical wisdom out there regarding ensuring the well-being of a pregnant woman for the whole term of her pregnancy. Tam Fry, director of the Child Growth Foundation, was quoted in The Observer when this policy was announced as saying:
“By the time a woman falls pregnant, she already needs to be eating well”.
Daghni Rajasingam, speaking on behalf of the Royal College of Obstetricians and Gynaecologists, said at the time:
“If a woman is not already eating a healthy diet by that stage”—
“then encouraging them to eat more fruit and vegetables”
“is too late...Even for small babies it is too late, there is very little you can do to increase growth at that stage.”
So the emphasis on the 25th week is entirely misplaced. The Government should be stressing the need for pregnant women to learn good lifestyle and well-being habits and to unlearn some bad habits, such as those related to smoking and alcohol, at the earlier stages of pregnancy.
I do not remember much of my National Childbirth Trust classes before my first child was born, but I do remember two things. I remember the women being separated from the boyfriends and husbands at the very first meeting, and the men being put to one side and given a game to play. We were given a diagram of a female body and about 25 labels, and we were asked whether, as a group, we could label a woman’s body correctly. I think that we scored under 75 per cent., which suggests that men should tread carefully when talking about such issues. I also remember the emphasis that was put at the very outset of those classes on the importance of diet and good lifestyle. There was no discussion of the 25th week and of getting one’s act together at a late stage of pregnancy; the focus was always on sorting out the issues—giving up smoking, cutting down on alcohol, watching what one eats and eating good quantities of fruit and vegetables each week—from the very start. So the focus on 25 weeks is misplaced.
I want in a very gentle way to raise with the Minister a question that is not purely hypothetical. There is some discussion in all parts of the House of the termination of pregnancies at this time, and whether there is a need to look again at the upper-term limit and to reduce it. What would happen if, the two Houses in this Parliament being willing, the upper-term limit were reduced to, say, 22 weeks? Would there be a need, therefore, to move the timing of the cash payment back, in line with that? If not, in theory a pregnant woman could legally make a claim for the grant and also legally terminate a pregnancy. I am talking very hypothetically, but I would welcome a response from the Minister because termination limits is a live discussion.
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