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Mr. Bradshaw:
As I was saying, amendment No. 2 introduces a new main objective for the commission. We have been clear throughout that the commission’s main priority should be the safety and quality of services, and I said early on that I thought that its key functions and responsibilities were already set out in what was clause 2. However, we recognise that many people thought that this was not expressed clearly enough. The amendment introduces a clear, succinct statement of purpose, which resists the temptation to stray into other territory and
create for the commission additional broad functions that it would have been unclear how it was to deliver, or to include a long list of objectives that could duplicate the functions of other statutory bodies. Instead, it emphasises that the welfare of patients and people who use social services should be at the heart of everything that the commission does.
Amendment No. 3 amends the matters to which the commission must have regard and sets those out in a separate clause. We were initially cautious about creating too many general requirements in these areas that risked diluting the commission's priorities. However, we have been persuaded on two particular fronts to make changes that, through their careful construction, address key concerns about the regulator’s focus on people who use services, but still preserve the right balance. Those are the reference to Local Involvement Networks—or LINks—which relates to amendment No. 72 in the next group, and the expansion of the responsibility to promote and protect people’s rights.
Another key issue in both Houses has been the desire to secure patient and user engagement in the commission’s work. We set out from the outset to create a body with a strong user focus, just as the existing bodies have. I have put on record my expectation that the commission will not only work closely with LINks but will find ways to engage with people who use services on a broader basis. Through Lords amendments Nos. 4, 24 and 25, we have responded to requests for this expectation to be set out explicitly in the Bill. Amendments Nos. 24 and 25 make it explicit that the commission must demonstrate to Parliament, as part of its annual reporting, how it is delivering against its statement on engagement.
Amendment No. 66 also responds to one of the key themes of the debates—the importance of ensuring that social care and the commission’s responsibilities under the Mental Health Act 1983 are not neglected. We have given assurances in both Houses that that would not be the case, but various amendments were proposed to try to guarantee it by legislative means. In amendment No. 66 we have arrived at a solution that provides the reassurance that some people have been looking for without tying the commission’s hands. It will include a broad requirement for the board to include members with expertise relating to all three areas covered by the existing bodies: social care, monitoring the use of powers under the 1983 Act, and health care.
We believe that the amendments improve on what was already in the Bill to make much clearer what is expected of the commission, without telling it how it should approach its task, and I commend them to the House.
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Mr. Stephen O'Brien (Eddisbury) (Con): I welcome this group of amendments, which delivers some of the changes that we were looking for, notably the inclusion of LINks—Local Involvement Networks—carers and service users, and proper representation for those with experience of health care, social care and functions under the Mental Health Act 1983. Unfortunately, it still fails to give the full independence needed for an effectively functioning regulator.
Amendment No. 1, which simply creates space for amendments Nos. 2 and 3, is uncontroversial. Amendment No. 2 inserts a new clause on the commission’s objectives.
I welcome that new clause, brought forward by the Government, as it responds to Conservative amendments from the other place and this House. I pay tribute to those on the Conservative Front Bench in the other place, particularly my noble Friend Earl Howe, on winning so many concessions from the Government. Indeed, a large number of the substantive Government amendments before us today come as a direct result of amendments tabled by Conservative Front Benchers in Grand Committee.
Members of the Committee in this House will well remember that amendment No. 2 was originally tabled, in similar terms, by me, supported by my right hon. and hon. Friends and others from other Opposition parties—and the Minister is now introducing it himself. In Committee in this House, the Minister said:
“we believe that the essence and desires behind the new clause are already in the Bill”
and called attempts to lay out the objectives
“flawed and unnecessary”——[ Official Report, Health and Social Care Public Bill Committee, 15 January 2008; c. 186.]
I hope that the Minister will take the opportunity to explain to the House why his colleagues in the other place disagreed, and whether he still considers such an amendment “flawed and unnecessary”. Surely it would have saved much parliamentary time to have accepted the amendment in Committee in this place.
Mr. John Redwood (Wokingham) (Con): My hon. Friend is making an important point. Does he have any explanation for the flip-flop, or U-turn? Is this a rare occasion when a Minister has listened and realised that he was wrong?
Mr. O'Brien: The best I can say to my right hon. Friend is that I would like to think so. I recall saying at the outset of the Committee that as we were aiming for as much consensus as possible on health and social care—not areas that are normally given to the playing of the party political game—I hoped that the Minister would avoid being tribal or having pride of authorship in the Bill. It was clear to us during the course of the Committee that accepting any Opposition amendments would cause the Minister physically to wince, so he did not accept one. Now we are back, mainly to implement the Conservative amendments, conceded in another place, that we presented in Committee. In answer to my right hon. Friend, there is a genuine question about what the price of saving face, or the price of not thinking quickly enough on one’s feet, is. As so much parliamentary time could have been saved had the amendments been accepted when they were first proposed, it is fair to ask precisely what has changed the Minister’s mind in the interim.
There are indeed some questions about the new clause. A number of hon. Members, and their lordships, have expressed concerns about the picture of the Care Quality Commission painted by the report “Developing the NHS Performance Regime”, recently published under the aegis of the NHS chief executive. Paragraph 150 states:
“The main responsibilities of the CQC are to: register health and social care providers; carry out a periodic assessment of all NHS...patient pathways or into other areas of concern or risk in terms of patient safety; carry out investigations into specific organisations where CQC believes that user safety is seriously at risk; and gatekeeping and proportionate regulation.”
“However, the principal role of the CQC will be to register health and adult social care providers.”
“The registration system will be a key function of the CQC. In operating this, the regulator will register, monitor compliance and take action in relation to healthcare providers’ adherence to the registration scheme.”
Furthermore, paragraph 100 states that
“the CQC’s approach to assessing the performance of NHS organisations includes their assessment of quality and of financial performance. Our expectation is that the CQC will continue to work closely with the Audit Commission on the latter”.
However, what is the expectation for the former—assessment of quality?
The document not only flies in the face of the amendment, which does not mention registration, but drives a massive wedge between the CQC’s social care and health care responsibilities. The NHS chief executive wants the health care side to be divested of performance monitoring, but presumably such monitoring will be built into the social care side. The chief executive reveals his hand in paragraph 100, which says:
“we cannot have the same organisation being identified as ‘weak’ by the CQC and not identified as ‘underperforming’ by SHAs as performance managers”.
Could that be construed as the chief executive wanting to keep the dirty laundry in-house instead of supporting the quasi-independent CQC?
It remains clear that our model of separate independent regulation of quality and finances, which, sadly, was rejected in Committee, is much more transparent, effective and likely to support world-class patient care. I hope that the Minister will take the opportunity to explain the contradictory messages that the Bill and the Department are conveying.
I welcome most of Lords amendment No. 3. Again, I pay tribute to the Conservative Front-Bench team in another place, whose amendments in Grand Committee inspired it. I am especially glad that Local Involvement Networks have finally made it on to the face of the Bill. I know that hon. Members in other parties will also welcome that.
I welcome Lords amendment No. 72, which is in the next group, and adds the commission to the list of those to whom Local Involvement Networks must send copies of their annual reports. Again—I do not want to cause too much controversy—the Minister was strident in his opposition to the inclusion of LINks. He told me in Committee:
“I do not think that the amendment requiring a statutory relationship with LINks is the right way to go about the matter... I am not sure that singling out LINks for special treatment in the form of a statutory relationship...is the right way of going about it.”—[ Official Report, Health and Social Care Public Bill Committee, 10 January 2008; c. 152.]
“we do not believe that it is appropriate to dictate to those statutory and independent bodies the way in which they should involve LINks in inspections or consultations.”—[ Official Report, 18 February 2008; Vol. 472. c. 88.]
What has changed? Of course, a late concession is better than none, but the Minister should have been prepared to change his mind when we discussed those matters in Committee, rather than waiting until such a late stage and taking up the House’s time.
I welcome proposed new subsection (1)(d) in Lords amendment No. 3, which recognises that the commission has a responsibility
“to protect and promote the rights of people who use health...care services”
and I remind the House that we debated that matter in Committee, and again the Minister was unwavering about it. The Government previously extended the provision only to children and vulnerable adults. Conservative Members believed that the CQC should promote the rights of all people, including those groups, but not excluding others. I am glad that the Government saw reason in another place. Again, I regret that the Minister did not see it sooner.
I regret that the Government have retained clause 2(4) in proposed new subsection (2) of Lords amendment No. 3. As the provision is drafted, the CQC must still
“have regard to such aspects of Government policy as the Secretary of State may direct.”
That makes nonsense of the idea of independence. I accept that the Minister has made several concessions to the independence of the bodies that the Bill creates or modifies—but those leave the provision that I have just cited looking rather out of place. Through it, the Secretary of State retains significant control over the CQC. In addition, clause 42 provides that the Secretary of State
“may direct the Commission to devise indicators”
That is a retention of politically motivated targets, and the Bill is peppered with similar phrases.
Dame Denise Platt stated in her powerful evidence:
“We think that the independence should be clear. The body should have the opportunity to think, initiate and comment and to be accountable to parliament for what it does”—[ Official Report, Health and Social Care Public Bill Committee, 8 January 2008; c. 14, Q18.]
I am not sure that the Bill provides for that sort of independence. It contains many phrases along the lines of “with the agreement of the Secretary of State”.
Speaking about clause 41, the Healthcare Commission stated in its submission:
“there is a risk of conflict with the independence that the Bill envisages for the regulator”.
“We do not think that the Government should determine operational priorities for an independent regulator.”
The independence of the regulator is key to freeing our NHS from political meddling. It is sad that the Government have not taken the opportunity to work towards that. The regulator will have the full confidence of the patients and front-line staff only when quality is its sole driver, not the political desires of the Government of the time. I am glad that we have won that and other concessions, but until the Secretary of State’s power as set out is removed from the Bill, it does not go far enough.
As for LINks, I welcome Lords amendment No. 4 and its focus on service users, which has yet again been underpinned by amendments from the Conservative Front Bench in another place and a new clause proposed by me in Committee. I welcome the fact that, through Lords amendments Nos. 24 and 25, the CQC will be
required to report on user involvement. The Minister rejected our proposals in Committee on the grounds that the advisory committee that the commission must establish under schedule 1 could allow such involvement. I am glad that he has changed his mind, but I would be grateful to know why.
Mr. Redwood: Is all this not just more evidence that the Government cannot get away from centralised, target-setting, interfering bossiness, messing up the health service and not allowing innovation and professional choice?
Mr. O'Brien: My right hon. Friend reaches for the overarching principle that lies behind the mindset that informs Bills of this type. The Government have an opportunity to pick up on the enormous amelioration that we could have, in resettling the basis on which the NHS can deliver, organically and from patient-driven demand, improved health care outcomes, rather than having an input-driven, target-setting approach. That is set out in our autonomy and accountability Bill, which has been drafted by the Opposition and is ready to go. I am grateful to my right hon. Friend for giving me the opportunity to ensure that, if that opportunity had slipped the Government’s mind, it is now before them again.
We also welcome the explicit mention of carers at the end of Lords amendment No. 4. However, I note the circularity that persists in the Bill, in Lords amendment No. 5, which states that in Chapter 1,
“‘health and social care services’ has the meaning given by”
clause 3, entitled “The Commission’s objectives”. Clause 3 defines “health and social care services” as
“the services to which the Commission’s functions relate.”
“The Commission has the functions conferred on it by or under any enactment.”
The Government have failed to investigate not only public health and health inspections, but adequate protection in the areas of cosmetic surgery, needs assessments for care, and health-related assessments for work, as regards the personal capacity assessment and health assessments in custody.
Lords amendment No. 66, the final amendment in the group, ensures that the commission includes representatives of health care and social care, and action under the Mental Health Act 1983. I am glad that the amendment has been tabled, because the Minister strongly resisted such a proposal in Committee. We might have progressed through the opening clauses of the Bill much more quickly had the Government made that concession then. I note, for example, that in oral evidence the Mental Health Act Commission made clear the need for
“adequate organisational and personal accountability at board level for the monitoring of and reporting on the needs and rights of detained patients.” ——[ Official Report, Health and Social Care Public Bill Committee, 8 January 2008; c. 9, Q9.]
The Minister rejected our overtures, saying that our proposals
“specify a great deal more prescriptive detail than we feel happy with...We believe it should be for the commission itself to establish the organisational structures...That should extend to the executive team it chooses to have...Specifying that the commission must have executive officers and committees that lead on different
client groups could undermine the commission’s ability to adopt that integrated approach”. ——[ Official Report, Health and Social Care Public Bill Committee, 10 January 2008; c. 134-35.]
I would be interested to know what has changed the Minister’s mind, in terms of the content of Lords amendment No. 66, between then and now.
Sandra Gidley (Romsey) (LD): It would be churlish not to welcome the amendments, particularly those that reinforce the importance of social care. Given that most parties have tried to work together on some of these issues, it is a little churlish of the hon. Member for Eddisbury (Mr. O'Brien) to claim that every amendment in the other place resulted from the efforts of the Conservatives alone. I have read the Lords Hansard, and that is not quite my perspective—but I will move on.
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