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When merging the Mental Health Act Commission, the Commission for Social Care Inspection and the Healthcare Commission, I hope the Government will take on board the fact that there is such an overlap of service out there, and rightly so. The service that we should seek to provide, particularly for patients, should be seamless, but despite the Government’s best efforts to merge health and social services, we all still come across a great deal of casework in which it is difficult to take matters forward because of the glass walls that seem to exist between areas of responsibility.
The care quality commission that the Bill creates will be responsible for inspection and standards and will, we hope, facilitate crossover and ensure the seamless delivery of services. If the system is too compartmentalised, people’s conditions and the difficulties that they are encountering will fall down the middle. I am sure the Minister will take that on board. We need to address the matter, not least because, in the context of inspection, there are some groups for which we will have to provide to make sure that the services that are delivered to them and the way in which those services are delivered do not disadvantage them. I shall give two quick examples.
Across health and social services, we talk about adolescents, but whether we are talking about physical health, mental health or social services, all too often adolescents find themselves in inappropriate situations because sometimes it is difficult to judge whether children’s services or adult services are best for them, for obvious reasons. They are young people going through the transition from childhood to adulthood, and tailoring the services and the quality of the service or care that they are given can be a difficult call for professionals. I hope the Minister will accept that whatever system is put in place when the care quality commission comes into being, it will need to address the particular circumstances of adolescents and ensure that the service meets their needs and that the inspection reflects the issues.
Another aspect of the care quality commission that I want to raise with the Minister is the fact that the Government want to take away from the people responsible for inspections the right to look into second stage complaints from individual patients or, occasionally, patients’ relatives. Although the Bill does not focus primarily on that, will it give substantial reassurance about the system that is likely to replace that? I know that the Government are going out to consultation, but many of us feel unhappy that something is being taken away before we have a clear idea of what will replace it. I hope the Minister will address that.
Another issue that I shall touch on is the extension of direct payments. I declare an interest, as I am responsible for assisting a dependent adult relative who is the recipient of direct payments. I take co-responsibility with him and help him to complete his forms. I have been a great advocate of direct payments so I welcome the extension proposed in the Bill, but I flag up a concern. Apart from my constituency casework, wearing other hats I get involved in other casework around the country. Some authorities administer direct payments well, and others do not. Some seem to think that that is a cheap option.
Some authorities could serve as models of best practice from which others could learn. Will the Minister consider looking at those that perform particular functions well in order to encourage the others to go and learn? For example, I mentioned that I helped with paperwork. In the authority that I deal with—I should tell the Minister that it is not an authority in Devon—the process has been made so simple that it is a joy to undertake. In some authorities, however, where people have been asked to make arrangements to buy in their own services, existing services have been removed and people have been left floundering, trying to find out where they can buy in.
The extension that the Government propose deals particularly with extending direct payments to those who lack capacity. They will be least able to shop around without a little guidance, not least to ensure that they are buying from a bona fide provider. We all know the difficulties for those who lack capacity, especially if they are not assisted by an immediate carer. Not all of them have an immediate carer to guide and assist them in buying in their package. Direct payments are a great idea, but one or two details need tidying up in order to improve the service, especially if it is to be extended to that group.
I was not in the Chamber earlier, so I shall not dwell on my next point. I flag up to the Minister a concern about clause 145, which deals with electronic records. I am sure that my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) on the Front Bench and others raised the matter. In the light of recent events, there is clearly a need to get the provisions spot-on. I hope the Minister will go back to the drawing board to make doubly sure that this part of the Bill will be a new dawn in the collation and management of electronic records.
The House has been generous in allowing me to speak, even though I was not present earlier. I have one further point. Across health and social services, there is one group of people who worry us all enormously. In his speech my hon. Friend the Member for Broxbourne (Mr. Walker) touched on the care of the elderly. There are issues such as end-of-life care, of which we have all had experience in our personal lives or in the casework that we have dealt with.
The Government should focus on the inspection and delivery of end-of-life care. Very elderly people, often unsupported by immediate family or friends, struggle when they go into hospital or into residential or nursing care, at a time of their life when the service should be a Rolls-Royce service. If we do not give priority to people at the very end of their life, that is an indictment of us as a society and as a country. I hope the Minister will bear that in mind when he brings the Bill to the Committee.
8.27 pm
Mr. Stephen O'Brien (Eddisbury) (Con): It is a privilege to follow my hon. Friend the Member for Tiverton and Honiton (Angela Browning), with her deep commitment and expertise in health and social care. I pay tribute to all that she has done to help all of us in the House, without fear or favour, to chart our way through difficult and sensitive matters.
We have had wide-ranging debate this evening, as befits such a wide-ranging Bill. My hon. Friend the Member for South Cambridgeshire (Mr. Lansley) called it a portmanteau Bill. My right hon. Friend the Member for Witney (Mr. Cameron) has made it clear that when the Government are doing the right thing for the country, we will work with them. Indeed, we will encourage them to go further, where that is the right thing to do.
In some crucial areas the Bill does not go far enough. Although we support it in principle, and do not intend to divide the House on it tonight, we look forward to developing the Bill to benefit patients and front-line health care professionals, not least by importing aspects of our own White Paper, which we have already published—although I shall, of course, try to stay in order. I am aware that Ministers have been provided with copies, which I hope they have read from cover to cover. We have published the NHS autonomy and accountability Bill, which, unusually, we will introduce during this Session. We want to include, at last, our proposals for a genuine patients forum that has teeth and independence—HealthWatch.
We looked in vain in the Bill for the vision and the overarching transformation, the prospect of which the Prime Minister, on taking office recently, highlighted. However, so far we have been disappointed, as was rightly noted by my hon. Friend the Member for Preseli Pembrokeshire (Mr. Crabb) in an analytical and powerful speech; I hope that we shall have his cogent participation in Committee. My hon. Friend was right to observe that the Bill is no testament to the Prime Minister’s aspiration for a vision—if, that is, he is still looking for one.
It is also worth noting that of 161 clauses, 38 depend on future regulations, the majority of which will be subject to the negative procedure. It is a great shame that the Government are too nervous, or lack the confidence, to bring forward a substantive debate on the Floor of the House on many of the measures. We shall seek to debate them in Committee, and I hope that the Minister will make available to the Committee in good time the draft regulations and examples, so that we can debate the best interests of patients and the public, rather than the leviathan power of the Secretary of State.
It would have been helpful of the Minister to have started by demonstrating his good intentions and informing the official Opposition that he was publishing today—the day that we are debating the Bill—the draft section 60 order. He did not mention that to me at the briefing meeting that we had a few days ago. I hope that he will be able to make up for that lack of foresight.
We might also note that 10 of the major provisions in the Bill do not carry an impact assessment, including the creation of the office of the health professions adjudicator, the health in pregnancy grant and the devolution of the pharmacy global sum to primary care trusts. One has to wonder whether the Government think so little of their own policies that the impact is not worth assessing. More worrying is the question of whether the work has been done, and is available for scrutiny by the House.
The hon. Member for Caernarfon (Hywel Williams) discussed cross-border concerns. As an MP with an English constituency that borders Wales, I am all too
well aware of the complexities and difficulties, and the fact that citizens on both sides of the border often seriously feel that there is a lack of fairness in respect of the health or social care provision that they receive.
Rob Marris: The hon. Gentleman has been following the Bill a little more closely than I. Can he tell us whether there is a legal aid impact assessment, which I believe all Bills should have? There may be a legal aid aspect; people may go to the new body for assistance with judicial review, for example.
Mr. Barron: Declare your interest.
Mr. O'Brien: The Chairman of the Health Committee has just said that I should declare an interest: recorded in the Register of Members’ Interests is the fact that I am a non-practising solicitor.
Mr. Barron: I was talking to my hon. Friend the Member for Wolverhampton, South-West (Rob Marris).
Mr. O'Brien: I do not know what the current status of the hon. Member for Wolverhampton, South-West (Rob Marris) is in the law.
I hope to develop this point a little later, but it is interesting that the proposals are not clear about whether somebody subject to the adjudication process has rights of representation. They might need to avail themselves of legal aid, irrespective of the hon. Gentleman’s point. I have not seen whether there is a legal aid impact assessment, but the fact that I did not see one on my first reading did not surprise me.
I should like to highlight the point made by my hon. Friend the Member for Tiverton and Honiton on the direct payment extensions. There is unquestionably a lot to be done to iron them out so that they are smooth-running. However, there is no question but that as a matter of principle they are the right way to go when they fit the circumstances of both the cared-for person and the person who assists. Most importantly—and this point cross-refers to other elements of the Bill—my hon. Friend was absolutely right to highlight the fact that the Government have not put forward proposals for benchmarking and the transfer of best practice. That proposal was extremely constructive. I hope that we may have the benefit of hearing more about it if my hon. Friend is lucky enough to be considered to serve on the Committee.
In his authoritative and all-encompassing speech, my hon. Friend the Member for South Cambridgeshire made clear our position on the care quality commission. [Interruption.] I did have to say that—because my hon. Friend’s speech was considerably more impressive than the Secretary of State’s. The Government are moving in the right direction, but they have not gone far enough, as I have said. In the simplest analysis, the CQC will not be independent of Ministers, despite the Secretary of State’s claim. As the hon. Member for Wyre Forest (Dr. Taylor) observed, the legislation fails to set out the commission’s core duties and responsibilities beyond the most anodyne of statements coupled with a crude fining system. At this point, we should note the genuine demand for the seamlessness mentioned by my hon. Friend the Member for Tiverton and Honiton.
I hope that the Minister will take the opportunity to answer the question put by my hon. Friend the Member for South Cambridgeshire. It was about the Appointments Commission, which is currently responsible for the appointment of the chairs of the Healthcare Commission and the Commission for Social Care Inspection. In his answer, the Secretary of State said that that would not be the case for the CQC because the job was so important that it could not be left to the Appointments Commission. That answer was most surprising, and I dare say he may reconsider it.
Until our proposals for an NHS autonomous of ministerial meddling, with separate and independent quality and independent regulators to support it, are delivered, the Bill will do little more than bring about an amalgam of existing bodies, with their existing constraints. Furthermore, without a strong national patient voice, that regulator will lack the necessary checks and balances to operate most effectively . We hope that the Bill provides the opportunity for us to seek to strengthen LINks to provide that.
The hon. Member for Blackpool, North and Fleetwood (Mrs. Humble) rightly advocated listening to the voice of the user. The hon. Member for North-West Leicestershire (David Taylor) advocated the use of citizens councils; that idea might go a little further than most of us would wish. However, I hope that his point is at least explored in Committee so that we can discuss its merits and demerits.
Another question was raised that remains unanswered; perhaps the Minister will take the opportunity to answer it when he winds up. In the development of the new institutions, the complaints system is effectively being taken back fully in-house. There is a big question mark about the absence of true independence; a question was raised about whether the health service ombudsman has the capacity to deal with the anticipated higher incidence of complaints that will find their way to his desk. That point, too, was emphasised by the hon. Member for Wyre Forest. I hope that the Minister will clarify the issue.
Many organisations have expressed concern that the experience built up by the Mental Health Act Commission, the Commission for Social Care Inspection and the Healthcare Commission will be lost. We shall seek assurances from the Government that the establishment of the CQC will not mark yet another year zero, particularly given the continual upheaval that the Government have brought to social care regulation. My hon. Friend the Member for Broxbourne (Mr. Walker) made a serious and passionate speech in which he made it clear that we also need to make sure that the Government give assurances that the social care and mental health responsibilities of the CQC will not be squeezed out by its Healthcare Commission-type functions. For example, have the Government made allowances for the impact of community treatment orders on the work of the MHAC? What work will the CQC do in prison health care? That point has not been raised. We should consider the point, raised by my hon. Friend the Member for Worthing, West (Peter Bottomley) in his excellent and comprehensive speech, about the appropriate use and deployment of magistrates under the Bill.
My hon. Friends have deplored the Government’s failure to combat health care-associated infections effectively. That the Government are embarrassed by that is clear from the fact that the relevant provisions are buried deep in the Bill. However, we guarantee—as will others from across the House, I am sure—to make sure that Ministers are engaged in a frank and open debate as we go through the Bill’s parliamentary stages.
As for professional regulation, we want proportional regulation that protects patients and the public, as well as innocent doctors. My hon. Friend the Member for South Cambridgeshire flagged up our debates on the role of the office of the health professions adjudicator. If Ministers believe in self-regulation, as we do, why is the OHPA required? We must leave that question hanging for them to answer, today or in Committee. It was interesting to hear from the right hon. Member for Rother Valley (Mr. Barron) about his experience of serving on the General Medical Council, which raised the question of why it is necessary to have another body in addition to developing the role of the GMC. His speech was restricted to that subject, but I hope that as Chairman of the Health Committee he will devote some time to, and take equally seriously, the social care aspects of the Bill.
Rob Marris: Does the hon. Gentleman agree that we need state regulation of psychotherapists?
Mr. O'Brien: I might have to lie on the couch to think about that. I do not see it as being within the scope of the Bill—far from it. It is the subject of numerous submissions and considerable argument, and it would be much better for us to discuss it in a rather more serious and considered way than in this very short exchange.
My hon. Friend the Member for South Cambridgeshire has helpfully found an assurance for the hon. Member for Wolverhampton, South-West on his earlier intervention about the legal aid test. I draw his attention to annexe C1 of the impact assessments document, which says:
“As stated in the evidence base, it is not expected that the number of orders made to a justice of the peace, (currently approximately 10 orders per year) or the numbers of prosecutions (currently none brought) will significantly increase. Therefore there is likely to be little impact on the work of the courts. Consistent with this, there is likely to be little impact on legal aid.”
It does not address the question of the impact on the health service ombudsman, who would be the point of appeal of last resort.
There is another matter that we need to be clear about as regards professional regulation. We know for sure that strong submissions will be made to the Committee about the proposals on the standard of proof. I reconfirm that we support the change from a criminal to a civil burden of proof in principle, but the Government have not yet provided clarity on the flexibly applied nature of the imposition of the new standard. We will not only seek to draw out the likely impact of the changes but seek assurances on the application of the sliding scale. I submit that evidential proof should be to the civil standard but, given that the ultimate sanction is to deny somebody their living, the procedural rules should be as for a criminal case, where someone knows the evidence against them well in
advance and has the opportunity to test it extensively. I also hope that the Government will entrench in the Bill a more positive approach to professional regulation, bringing greater opportunities for benchmarking and professional development.
Hon. Members raised several points about public health and health in pregnancy. My hon. Friend the Member for Guildford (Anne Milton) will take those matters through Committee, so I shall leave them for her to develop extensively. Interestingly, the miscellaneous provisions are quite substantive. In its breadth, the Bill gives us an opportunity to debate several key issues regarding the provision of health and social care. Sadly, the solutions proposed by the Government do not appear to be sufficient or sufficiently focused. That is true of this Bill as of so many others. That gives us the chance to try to improve it immeasurably, and I hope that we can do so for the sake of the future health care of our constituents, patients and the public. It is our social responsibility to give them the social care that they deserve.
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