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The Care Quality Commission will be established as an intelligent regulator. It will take account of a whole range of information to assess risks in respect of providers and the services that they provide. Based on that, it will decide when and how frequently to visit providers and which issues require more detailed investigation. That will build on the approach already being developed by existing regulators to target inspection when action is
required. It will therefore not be for the Secretary of State, but for the commission, on the basis of its intelligence, to determine the appropriate triggers for inspections over and above what is set out in regulations. I invite the hon. Member for Romsey (Sandra Gidley) not to press the amendment.
Mr. Stephen O'Brien: We are discussing Government amendment No. 62 and the ensuing ones in the group; again, we have a host of Government amendments. Some are concessions that have arisen from Committee, but the question remains about why they had to appear at this late stage.
In amendment No. 62, the Government are making an important concession on patient and public involvement in health. The Government promised a number of times in Committee to revisit the issue on Report. The drafting of the amendment is, to say the least, disappointingly unambitious. I am concerned that the amendment will open the door for any group that claims to speak on behalf of members of the public to harangue the new commission. We will return to the issue when we discuss the next grouping of amendments, but why are the Government fighting so shy of putting LINks—the bodies that they have created—into the Bill? Surely that is not because they have no confidence in the bodies themselves. Is it that, as the hon. Member for Tamworth (Mr. Jenkins) pointed out in Committee, the Government are worried that the bodies will be disbanded in the near future, following hard on the heels of the community health councils and the forums?
I hope that the Minister will expand on amendment No. 68; in Committee we had a number of discussions on the withholding of mail from prisoners detained under the Mental Health Act 2007, an issue of specific concern to the current Mental Health Act Commission. Can the Minister guarantee that the status quo will not change?
The hon. Member for Romsey (Sandra Gidley) tabled amendment No. 142 to clause 57, which is concerned with regulation. Clause 64 is entitled “Avoidance of unreasonable burdens in exercise of regulatory powers”. We have proposed that when the CQC increases regulation, an affirmative resolution should be brought before the House. We found that the Government were most resistant to that idea; as I have placed that on the record, I hope that the matter will be taken up with alacrity and fierce argument in another place.
The amendments on the CQC go hardly any way towards addressing the many and deep concerns expressed by the Committee and a number of third-party organisations; the letter published in today’s issue of The Guardian testifies to that. It seems to suggest that the Government have lost the confidence of a lot of members of the voluntary sector. There is still no mention of carers among the skeletal functions of the CQC, listed in clause 2. I say “skeletal”, because for the most part this is skeleton or portmanteau legislation—the body is to be added later, by regulations. That is most noticeable in clause 2, which establishes no overarching function. Indeed, the advertisement for the chair of the commission, already online despite the fact that the Bill has not been passed by either House, states that one of the role’s responsibilities will be developing plans for
the development of the commission’s functions—an interesting job spec if ever there was one.
There are still real concerns that social care and the work of the Mental Health Act Commission will be squeezed out in the action of the new commission. To ameliorate the problem, we have sought a separate reference board of commissioners and an executive board to run the commission. Despite the Minister’s contention that the CQC is to be free to establish its own direction, the Government have not left space in the legislation for it to establish the most effective system of corporate governance. Furthermore, there are real concerns that the Government are playing politics with the merger, and ultimately with the well-being of patients and service users, through the prevention of special reviews until after 2010—that is, after what will be an increasingly rocky election period for a failing Government and a dithering Prime Minister. We will seek to overturn the issue in another place to prevent that politicking from influencing the important substance of the Bill.
Dame Denise Platt of the Commission for Social Care Inspection has expressed concern that many of the commission’s functions will become permissive rather than statutory, as they currently are, and that they will therefore be the first to be ditched when the Government put on the financial squeeze. The Government seem unable to get the issue right. What guarantees can the Minister give that they will not scrap this in three years’ time?
The 1998 White Paper “Modernising Social Services” proposed structural change. The Care Standards Act 2000 created a single England-wide National Care Standards Commission, which was launched in 2002—17 days later, the Government announced that it was to be abolished. The Health and Social Care (Community Health and Standards) Act 2003 created the Commission for Social Care Inspection, which was launched in 2004, incorporating the social care responsibilities of the National Care Standards Commission, the work of the Department of Health social services inspectorate and the SSI-Audit Commission joint review team. In 2004, the Government’s arm’s length body review ruled out a merger with the Healthcare Commission. In his 2005 Budget statement, the then Chancellor announced the merger that we are debating today. Need I say more? Can the Government guarantee that all the work that we are putting in today will not be scrapped within three years?
This scandalous provision remains in the Bill. It forces the CQC to have regard to such aspects of Government policy as the Secretary of State may direct; as such, it totally undermines the independence of the body. The Healthcare Commission has put on record its concerns about the timing of the legislation and that the costs will be high and the distraction considerable. It was disappointing therefore that the Government chose not to include the cost of the merger with wind-up costs of £140 million in any risk assessment.
The House should also be aware that the merger is saving almost nothing on the efficiency trend that the three commissions themselves have already established just as they were bedding in. Taxpayers are paying £140 million for a merger and rebrand that will probably save them no extra money. Furthermore, parts of the cost savings are due to the commission losing the responsibility for complaints handling. That will be
transferred to the ombudsman, but we have had no costings on the increase of her budget in the face of an elevenfold increase in work load. We also have no information on how this will be wound up and transferred.
Despite all their amendments, the Government have yet again not got things right. They have not had sufficient ambition when they have sought to address the concerns that have been raised. I hope that the Government have only put down a marker for what will be truly beefed up, made proper and substantive in another place, so that health care needs are met and patient representation and protection are secured.
Sandra Gidley: When I first read Government amendment No. 62, I thought it a good idea. However, I had a cynical afterthought—I wondered whether it was a spoiling amendment for the LINks amendments tabled by the Conservatives. On the face of it, amendment No. 62 seems to address some of the many concerns raised in Committee about there being an insufficient patient and public voice in the new commission. However, I am not sure that the insertion of the words “or on behalf of” has been fully thought through. They are rather vague. It is not clear, for example, who decides who should speak on behalf of whom.
I can imagine the Government’s reaction if Opposition Members had tabled a similar amendment in Committee: we would have been told that there was no specificity and no clarity about who could speak on behalf of whom. Are we talking about bodies that have a constitution so that it is clear on whose behalf they speak, or advocacy services that may speak on behalf of the individual? Where is the protection for an individual who does not want anybody speaking on their behalf? Some mental health groups are very particular about their views on things, and I can envisage problems where other people might purport to speak on their behalf. I am a little confused by the vagueness and wonder whether any further clarity is yet to come.
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I thank the Minister for amendment No. 65, which almost deals with the concerns raised when we discussed amendment No. 239 in Committee. At that stage, his argument against the amendment was that there were occasions when vulnerable children or adults must be protected, and I wondered how that would be resolved. I do not mean to sound churlish. I am delighted to see the amendment, but curious about the reasoning.
Liberal Democrats tabled amendment No. 142 after discussion with Unison. We discussed the relevant issues in Committee, but there is still concern about the triggers for inspection. The Minister claims that that is dealt with in the Bill and that it is not a problem. However, there is a problem where an inspection is due within a prescribed period but there may be factors that would alert people to the need for an inspection to be done more rapidly. There may be risk factors that could, particularly in a care home, lead to the quality of care deteriorating rapidly where a provider had previously been rated “good” and placed on a three-year inspection cycle. Those could include a change of ownership of the provider—we have all seen cases of nursing homes where that has been evident—or a change of registered manager, which can have a huge impact. Adult protection matters may come to light. It might be
something as simple as staff turnover, sudden increases in which often indicate that something else is going wrong. If there is to be an automatic three-year inspection cycle, there must be an early warning system. We would not want to go back to a situation where there had to be a number of complaints before somebody realised that there was cause for concern.
The Government have said that the principles of inspection for the CQC will be “proportionate” and “risk based” with a view to lightening the burden of regulation for health and social care providers. We would all agree with that general sentiment. However, the new inspection methodology is much more reliant on paper-based reviews and providers assessing themselves. I have occasionally had that concern in relation to CSCI. Sometimes, the first person who is asked to provide a report when there is a complaint is the manager of the care home whom the report is against, and of course people will try to present themselves in the best light possible. There are concerns that the moves towards light-touch regulation could have significant implications for public and staff safety, at a time when the Government are trying to encourage more private providers into the market.
The Minister said that it will all be okay, but he has a job of reassurance to do. As the hon. Member for Eddisbury (Mr. O'Brien) highlighted, the budget that the new commission will operate with will be 40 per cent. less than what the previous regulators had, so it may be driven by budget imperatives rather than what is best for users of health and social care services. A recent survey of Unison members working for the CSCI found that 76 per cent. believe that the new inspection methodology does not provide a robust assessment of risk to service users. A common belief was that the reduced inspection programme could lead to staffing cuts, and fewer inspectors are less likely to impose enforcement requirements because there will not be enough time to follow them up.
It is not only me that the Minister has to reassure. A body of people out there are committed to doing a good job of work for CSCI, and deal with these problems day in, day out. They are concerned that problems will escalate unless there is a clear framework for alerting people to potential problems at a very early stage in the proceedings.
Kelvin Hopkins:
My hon. Friend the Minister may know that I have been to visit the Minister with responsibility for care homes with a delegation from Unison, and we expressed concern about the risk-based approach to inspection. I know that my hon. Friend gave assurances about this in Committee, but there are ongoing concerns. If, in time, there are cases of care homes where the lighter-touch inspection has led to a lowering of standards of care, or the sense that they will no longer be visited so frequently and therefore do not need to perform quite so well, that could eventually lead back to the Government’s door. My hon. Friend is conscientious and concerned about these matters, but this could come back to haunt the Government unless it works. We have already had reports in the past couple of weeks about care homes where there have been serious infections or the inspection was not sufficient to ensure that they had performed well. While I accept my hon. Friend’s sincerity about the matter, some will
continue to have concerns about the light-touch approach and the risk-based inspection system. This may have to be revisited in future unless it works as well as he suggests.
Mr. Bradshaw: I welcome the fact that the hon. Member for Eddisbury (Mr. O'Brien) recognises amendment No. 62 as an important concession, but it was not clear from his comments whether he was criticising us for going too far or not going far enough. I am not likely to get that clarification at the moment, as he is not here. The hon. Member for Romsey (Sandra Gidley) put her finger on it when she gave an example of how sensitive some patient and user groups are about organisations claiming to speak on their behalf. That is why we have broadened this out significantly to include groups who speak on people’s behalf, not just a single organisation, although I specifically referred to LINks. I urge hon. Members on both sides of the House to give LINks a chance before writing them off.
To reassure the hon. Member for Eddisbury on the retention of the status quo on the Mental Health Act 2007, I draw his attention to amendment No. 68. I could have gone into that in more detail, but that is what that amendment does with regard to the rules on the opening of post.
The hon. Gentleman asked me to guarantee that the new regulatory landscape will not be scrapped again in three years’ time. If, as I hope, there is still a Labour Government in three years’ time, I can give him that assurance. There was a general recognition in Committee that the Bill finishes the job that we began several years ago. In fact, as we discussed at some length, some Liberal Democrats urged this integration on us at the time of the last reorganisation of the regulatory system, but we felt that the timing was not right and that it made sense to allow the existing regulatory bodies to settle down and do their job—and they have done a very good job. Even from the bodies that face abolition, there was a recognition of the desirability of the principle of integration. Once that has taken place, everyone feels that we will need time for the new regulatory system to bed down.
In response to the hon. Gentleman’s question about the complaints process—something we discussed at some length—I draw his attention to the memorandum submitted by Ann Abraham on 14 January, which spells out clearly how she expects to meet this challenge.
Mr. Stephen O'Brien: I beg to move amendment No. 131, page 2, line 11 at end insert—
‘(aa) views expressed to them by Local Involvement Networks.’.
Mr. Deputy Speaker: With this it will be convenient to discuss the following amendments:
No. 136, in clause 92, page 45, line 47, at end insert—
‘“Local Involvement Network” has the meaning given to it by section 222 of the Local Government and Public Involvement in Health Act 2007 (c.28);’.
No. 132, in clause 103, page 51, line 8 , at end insert—
‘(aa) Local Involvement Networks,’.
No. 133, page 51, line 9, before ‘bodies’, insert ‘other’.
No. 134, in clause 112, page 56, line 16, after ‘public’, insert—
‘(aa) Local Involvement Networks,’.
No. 135, page 56, line 17 , before ‘bodies’, insert ‘other’.
No. 137, page 66, line 15, at end insert—
‘“Local Involvement Network” has the meaning given to it by section 222 of the Local Government and Public Involvement in Health Act 2007 (c.28);’.
Mr. O'Brien: I am grateful to you, Mr. Deputy Speaker, and I apologise for the fact that I had to absent myself briefly from the Chamber towards the end of the debate on the previous group of amendments.
We come now to local involvement networks, and it will not have escaped your notice, Mr. Deputy Speaker, that we had a partial discussion about them in relation to Government amendment No. 62, which sought to make clause 2 read:
“In performing its functions the Commission must have regard to—
views expressed by or on behalf of members of the public about activities to which the functions relate”.
I pay tribute to the co-sponsoring of our amendments by the hon. Members for North (Kelvin Hopkins), for North-West Leicestershire (David Taylor) and for Romsey (Sandra Gidley). Amendment No. 131 would make it explicit that LINks were one of the groups that the commission must have regard to. Amendment No. 132 would include LINks as a group that the Office of the Health Professions Adjudicator must seek the views of, and amendment No. 133 is consequent to that. Amendment No. 134 would include LINks as a group that the Commission for Healthcare Regulatory Excellence must seek the views of from time to time, and amendment No. 135 is a consequential amendment. Amendment No. 136 defines LINks for the purpose of part 1, and amendment No. 137 defines them for the purpose of part 2.
I welcome the concession that the Government have made to the arguments advanced by me and Committee members of all parties that LINks should be consulted by the Care Quality Commission. Unfortunately, having promised a number of times in Committee to revisit the issue on Report, the Minister has been disappointingly unambitious in his amendments, which were accepted without opposition. I will not suggest, therefore, that those amendments show more of the contempt that many, including me, have accused the Labour Government of showing in their treatment of the patient voice in England. They scrapped community health councils, which I was very involved with. I exposed an answer given at Prime Minister’s questions: the Prime Minister said that there had been consultation when it was announced that they would be axed in the July 2000 NHS plan, but there had not.
The patient and public involvement forums are now also to be replaced, and if LINks are not mentioned in the Bill, the Government’s latest solution could appear as a vote of no confidence in them. That perception is held by the hon. Member for Tamworth (Mr. Jenkins), who noted in Committee that the reason for not prescribing LINks in the Bill was
“in case it ceases to exist during the lifetime of the Bill”. ——[Official Report, Health and Social Care Public Bill Committee, 17 January 2008; c. 284.]
The hon. Member for Luton, North, who is co-sponsoring the amendments, told the Committee that
“ever since the community health councils were abolished Labour Members have been concerned about the strength of protection for patients and of patient representation”. ——[Official Report, Health and Social Care Public Bill Committee, 22 January 2008; c. 412.]
I admire him for saying that. He is right and it needed to be said.
I will not rehearse the arguments made in Committee, but simply note a few essential points in support of the amendments, the most vital of which is amendment No. 131. In December 2005, an independent review of the regulatory framework of the NHS, ordered by the Department of Health, concluded:
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