 House of Commons |
Session 2007 - 08 Publications on the internet General Committee Debates Health and Social Care |
Health and Social Care Bill |
The Committee consisted of the following Members:John Benger, Celia Blacklock,
Committee Clerks
† attended
the Committee
Public Bill CommitteeThursday 10 January 2008(Afternoon)[Mr. Jim Hood in the Chair]Health and Social Care Bill1
pm
Mr.
Stephen O'Brien (Eddisbury) (Con): On a point of order,
Mr. Hood, I would like to place on the record that although
I thank the Minister for the briefing he has put before the Committee
on delegated powers in the Bill—a briefing that I asked for at
the meeting we had after Second Reading—it was unfortunate that
it only arrived on the evening of 7 January, which was less than 18
hours before the Committee started. In the briefing, the Minister
stated that on publication of the Bill he
also
“published the
delegated powers memorandum for the Health and Social Care Bill by
placing copies in the House
Library.”
When I
contacted the Library yesterday, I was informed that it did not have
the memorandum. On further investigation with officials and with the
Library, I was told this morning—the information is rather
specific, so forgive me for quoting—that:
“This was a delegated
powers memorandum which does not fall into the category of deposited
paper unless it is specifically mentioned by a Minister as being placed
in the Library, therefore it was not given a dep number. It was sent to
the library but was obviously rejected as a dep by our deposited papers
clerk.”
I understand from
officials that they tried to deposit the paper in the Library but that
the Library refused to take it, presumably on the ground stated. This
morning, the Library has provided me with a hard copy of the
memorandum. The first mention of its existence was in the briefing that
I first saw just before the Committee met on Monday 7
January.
Although I
understand the difficulty, Mr. Hood, perhaps you could
assist me in ascertaining when the Committee was notified about the
memorandum and given access to it. Given that a quarter of the
Bill’s clauses are dependent on secondary legislation, the
memorandum is a key document for the proper working of the Committee. I
am anxious that there should be a timely consideration of all such
documents, so that we can scrutinise the Bill. I would be grateful for
your advice, Mr.
Hood.
The
Chairman:
Before I rule on the point of order, I invite
the Minister to respond to Mr. O’Brien’s
point.
The
Minister of State, Department of Health (Mr. Ben
Bradshaw):
Yes, I can do so briefly. My understanding is
that—and I apologise for this—my officials were not aware
of the new Library rule requiring some public commitment on the part of
the Minister that he or she will place a document in the Library.
Although I think that we have e-mails from way back showing that it was
our intention to do so, my officials and I were not aware of the
procedure. As
the hon. Member for Eddisbury has graciously acknowledged, we tried to
place the document in the Library, but it did not happen because of the
new
rule.
The
Chairman:
I appreciate the point made by the hon. Member
for Eddisbury, but it is not a point of order for the Chair. Having
raised the matter and had the Minister respond to it, perhaps the usual
channels can resolve the problem. It is not a matter that I consider a
point of order.
Clause 1The
Care Quality
Commission
‘with the
totality of their quality inspection functions and duties passing to
the Care Quality
Commission’.
At
the beginning of the first amendment, to clause 1, may I formally take
this opportunity in our line-by-line sessions to welcome you,
Mr. Hood, and your co-Chairman, my hon. Friend the Member
for Old Bexley and Sidcup (Derek Conway), to the Chair to deliberate
over our
proceedings?
As
is patently clear to all of us who have been studying the Bill for some
time, clause 1 introduces the Care Quality Commission—the body
that will take over from the Commission for Healthcare Audit and
Inspection, the Commission for Social Care Inspection, and the Mental
Health Act Commission. Clause 1(2) states that those three predecessor
bodies are to be “dissolved”. We have proposed an
amendment that would add after the word “dissolved” the
phrase
“with the totality
of their quality inspection functions and duties passing to the Care
Quality
Commission”.
It
is vital that I explain why the amendment is important. It is at the
beginning of the Bill and will, therefore, be important in relation to
many of the other things that we deliberate on. Most importantly, it
seeks to ensure that we leave as little doubt as possible for all those
who will have to put in place the arrangements contemplated under the
Bill—assuming that it has safe passage through the House. I
commend the amendment to the Minister and hope that he will regard it
as constructive, helpful, positive and not at all partisan, and as
something that will help those who have to implement the Bill. I hope
that he contemplates accepting
it.
The amendment
would establish continuity with the previous regulators, thereby
smoothing the transition, and clarify the costs involved. We have heard
a lot about transition in the last three sittings, during which we
heard helpful oral evidence. All the regulators as currently
constituted and many third-party groups have expressed concern at the
silence of the Bill on their future function, as embodied in the new
Care Quality Commission. Both the Commission for Social Care
Inspection—CSCI, as I shall abbreviate it for future
reference—and MHAC, the Mental Health Act Commission, have
expressed concern that their work will be curtailed due to the
merger.
CSCI has asked
me to alert the Committee to a letter that it has sent, outlining its
opposition to the Minister’s principled welcome to the Bill. It
might be helpful if we recall that, during the course of CSCI’s
evidence to us just a couple of sittings ago, it engaged in a dialogue
with the Minister. CSCI is concerned that an impression may have been
given about its public position in relation to the merger of the three
bodies that it does not feel necessarily fairly reflects its
position.
CSCI has
written saying that it has now had the opportunity to look again at its
statement of 24 October 2007—it was quoted by the
Minister—that was prepared following the publication of the
Department of Health’s response to the consultation on its wider
regulatory review and its decision to proceed with the creation of a
new Care Quality Commission, bringing together the functions of this
commission and the other two. The letter from CSCI
says:
“It did
not make reference to the Bill now before your
Committee.”
Indeed, the
Bill was only published on 24 October and given its First Reading on 15
November. That statement was posted on the commission’s website,
but it was not formally issued as a press release. CSCI, which is
relevant in respect of the way that amendment No. 1 works, notes that
in welcoming the overall policy direction, it also made it clear in the
statement that there was a “great deal of detail” yet to
be determined in the proposals. It
says:
“This
commission has always been of the view that a structural change in the
regulation of social care and health services at this time is
premature, however desirable that end might be in the longer
term.”
That is important,
because the amendment is intended to ensure that we have some
continuity, rather than the pitfalls that might attend to something
that is seen, by those who have the greatest experience and expertise
in that area, as
premature.
CSCI also
said:
“The new
organisation must have parity between health and social
care.”
On Second Reading,
the Secretary of State
said:
“My hon.
Friend”—
he was
referring to the hon. Member for Blackpool, North and Fleetwood
(Mrs.
Humble)—
“raises
the crucial issue with regard to the plan to merge the three current
regulators. Social care must have parity in the new commission. That
must be reflected on the board of the new commission and in everything
that the commission does. I am pleased that she has given me the
opportunity to reassert that that is the case, and that it needs to be
the case. That point will be emphasised throughout the passage of the
Bill.—[Official Report, 26 November 2007; Vol. 468, c.
37.]
Here is the opportunity for
the Minister to ensure that that is given a true manifestation in the
Bill.
CSCI also says
that if additional functions, such as around hospital cleanliness, are
not adequately funded by the Government, it fears that they will be
funded out of cuts to social care regulation. Moreover, it has been
asserted that CSCI has
already
“reduced its
recurrent operating costs by 33 per cent. in real terms between 2004
and 2009. The Government has also said that the new body will have to
operate on a substantially smaller budget than the combined current
budgets of CSCI, the Healthcare
Commission”
and
MHAC.
That is why
putting amendment No. 1 into the Bill after the word
“dissolved” would make it absolutely clear that in this
case—rather than looking at the quality inspection
functions—we are looking particularly at having the duties
passed to the Care Quality Commission, without there being a danger
that the things that CSCI has, over a relatively short period, worked
so hard to establish in the crucial areas of both care and inspection
fall through the gaps during what, as the Minister admitted, will
inevitably be a disruptive time as one goes through change. Disruption
attends upon any change.
In support of this amendment, I
am aware that it is always nice to have short and crisp amendments.
However, I know that there has been some discussion, through the usual
channels, about the first few amendments inevitably being some of the
more lengthily debated ones. Much of the ground that will be dealt with
later will be covered by this very important first amendment, which
would clarify the transition, the inspection functions, duties and
costs.
I therefore
move to the Mental Health Act Commission’s comments to help us
chart our way through this. In its press release on the launch of the
Bill, it said:
“The Mental Health Act
Commission is concerned that with the merger of its functions into a
large regulatory body with a wide variety of functions that monitoring
of the operation of the Mental Health Act and the protection of
vulnerable patients may not get the priority it
needs”.
Chris
Heginbotham, the chief executive of the Mental Health Act
Commission—whom we all saw the other day when he gave
evidence—said:
“Only by visiting
detained patients regularly and frequently can abuses be identified and
rooted
out”.
During
the evidence session, MHAC expressed the fear that their
focus
“will get lost in
a large organisation”——[Official Report, Health
and Social Care Public Bill Committee, 8 January 2008; c.
8.]
MHAC submitted
that
“There are six
functions or sets of functions, and the way in which those functions
are performed, that the MHAC considers to be vitally
important”
for the CQC.
Some are current powers; some are other powers that it would like.
Briefly and in short form, those six functions are:
“Visiting and
interviewing detained patients in private ... Engaging mental
health service users ... Adequate organisational and personal
accountability for monitoring and reporting on the needs and rights of
detained patients; Statutory notifications of admissions, discharges
and deaths of detained patients, and other relevant information;
Ensuring adequate and appropriately trained staff”,
and an equality and human rights focus.
That last will, of course, be the subject of a number of other
discussions as we proceed through the Bill, but of course it matters
even at this early stage.
A majority of third-party
organisations has also expressed concern about the merger, hence this
rather important approach to clarifying the purpose of the merger in
the amendment. Age Concern, in its submission on the Bill,
was
“very concerned that
overall funding for this super-regulator will be far less than existing
funding for the regulatory bodies that are being
replaced”.
Carers UK argued that
CSCI
“has built up
valuable expertise on carers’ issues and on social care more
broadly”,
and
that
“It is essential
that the new body is given sufficient power and resources to maintain a
focus on social care and that it is not dominated by
health.”
Help the Aged
said:
“CQC’s
budget must be sufficient to maintain frequency and quality of
inspection and to ensure that the new Commission builds on the work of
existing bodies — doing more, rather than
less”,
and
that
“Work on social
care must be given fair priority and resource allocation within the
Commission’s programme ... We are also confused by the fact
that Regulatory Impact Assessment for this Bill sets out that the cost
benefit of having one regulator rather than three depends on the scope
and responsibilities of CQC, which will be set out in secondary
legislation. This would seem to suggest that it is, as yet, impossible
to tell whether the new Commission will be cheaper...We are
seeking assurances from Government that CQC’s budget will be
adequate to maintain the quality and frequency of inspections and to
build on and develop the work of the previous organisations, rather
than reducing its
programmes.”
The
General Social Care Council believes that
“it is important that the
distinctive nature of social care and the values of social care
regulation developed by the GSCC and CSCI continue to be recognised in
the work of the
CQC”.
During
an oral evidence session the Association of Directors of Adult Social
Services said that any loss of focus in social care would concern
them.
1.15
pm
The amendment
would enable the commission to protect the current regulatory framework
and grow organically, rather than legislatively, out of that. It was
interesting that Which?, during oral evidence, commented that the Bill
does not set out a clear statement of purpose for the CQC. The
amendment would give protection against activities falling through the
gaps during transition or getting lost in a bigger organisation, let
alone defocused, because it is inevitable that priority is lost during
the admitted disruption and instability. We are already hearing
anecdotally of the inevitable recruitment and retention sclerosis that
is bound to attend upon the current proposals and the possible
demotivation of the people involved.
We will have
many specific questions over the course of the Bill so I will not tack
them on to the amendment. However, before the Minister contemplates his
response to the amendment, I want to highlight something that came out
for all us during the oral sessions—visiting rights. The
visiting rights called for by the Mental Health Act Commission could be
distinguished from the kind of visiting undertaken by CSCI and the
Healthcare Commission. The Minister made clear in his evidence this
morning that the Government do not think it right to dictate now
who—I interleave the commission—should visit, and how
often.
I hope that
amendment No. 1 would enable the Minister to underpin the assurance he
is seeking to give when addressing the very real concerns about those
who are most practised, most knowledgeable and most pragmatic in making
sure that—as managements and organisations—they have the
continuing capacity to deliver for incredibly important, needy and
often vulnerable people in our society.
Another point to highlight is
the ratings system. The CSCI is concerned that its quality ratings
system will fold—in particular the star-rating system for
individual services that it plans to start rolling out during 2008. It
is telling that the official questioned this morning noted that it is
highly likely that the annual health check for hospitals will remain
annual, but that the CQC will not need to do that for all its
investigations; so despite Government statements about parity of social
care, this morning’s oral evidence left us with the impression
that officials may consider that health care regulation is of prime
importance. I hope that the Minister can give us some genuine
reassurance about that.
The amendment covers the issue
of trying to identify the costs of transition, which I am sure are well
recognised. It is important that I try to get a handle on that as we
introduce the amendment. With regard to the costs of the merger, part
of the impact of the amendment would be to mitigate the variables in
the costings forecast for the CQC. A number of witnesses made
statements on costings during oral evidence. Dame Denise Platt pointed
out that this is framework legislation. Anna Walker noted that the
commission will need to be resourced to do the job that Parliament sets
for it and that the Bill is only a framework for that. The Minister has
made available to the Committee a briefing on the registration
requirements, which states that he is planning a formal public
consultation to inform the scope—that is, which services fall
within registration—and the requirements for registration. The
question must be put before the Committee, and again I hope the
amendment helps us with that. Without that information, how could the
Minister make the cost estimates that he has
made?
The regulatory
impact assessment identifies that the net benefit range from a gain of
£129.3 million to a loss of £52.7 million over the next
10 years, with a probable estimated benefit of £52.7 million
plus a net gain of £3.3 million on the administration burdens
baseline, is at 2005 prices. On 13 December, the Financial Times
reported that the Minister had confirmed wind-up costs of
£140 million, and there were departmental claims that it would
save £60 million per annum. We must try to identify whether the
amendment helps us to get a handle on that vital area of cost which,
given the claims made for the combination, must be understood.
Otherwise, we could be proceeding not only in the dark, but under false
assumptions.
Angela
Browning (Tiverton and Honiton) (Con): The regulatory
impact assessment says, in paragraph 1, that the costs mentioned by my
hon. Friend are based on the framework, and that a lot of them will be
identified only when the details are known. We are being asked to
legislate on something with a set of figures that is extremely broad,
and I wonder if my hon. Friend is minded to invite the Minister to
provide, during the course of the Committee, more outline detail as to
where those costs will fall.
Mr.
O'Brien:
I am grateful to my hon. Friend. I know that she
is very good at working with and using
costs and numbers, and I admire her for that as it is not a skill that
is overwhelmingly presented during parliamentary life. It is a serious
matter: costs matter, particularly in this case where so much is
claimed for the cost benefit of what is taking place. I have already
asked how the Minister was able to make his cost estimate, on the basis
that it was made only on outline frameworks, without the benefit of the
detail, and is still subject to consultation. Unless the consultation
is not meant to count for anything, and it is all done and dusted and
merely a question of going through the form, we are left having to make
assumptions.
That
is quite dangerous in the circumstances. If something is to become a
successor body to three existing, high-performing bodies in the public
arena, certainty is required above all, as there are many vulnerable
people for whom this will not be the same as if something is invented,
where we have a clean sheet of paper. There will be people with needs
that continue today, tomorrow and the day after the organisation is
established. If we do not have clarity about the costs, we are in grave
danger of making errors as a legislature.
Angela
Browning:
We need to mix into the equation the
question of fees that come from sources other than the
Government.
Mr.
O'Brien:
That is an important question. I do not know
whether my hon. Friend has had a chance to look at the terms of the
money resolution that will be debated on Tuesday on the Floor of the
House. As I read them, they are narrowly drafted in relation to the
fees that are expected to be paid to the chairmen of the adjudication
panels under the new determination procedures for continuing in
practice. Apart from anything else, there are serious issues about the
fact that the money resolution has come up at this stage, rather than
being tagged on to Second Reading as one might have expected. It will
look as though there have been subsequent negotiations, perhaps with
the General Medical Council and others, which have led to that change
at this late stage, and we will have some interesting timetabling
issues as a result of that being dealt with on the Floor of the House
at the same time as the Committee should be sitting.
My hon. Friend is right to
highlight the need to control, as well as understand, the external fees
required strategically to deliver the proposals into existence. The
fees are highly difficult to quantify but, if sufficient detail has
been produced, they should at least enable a realistic estimate rather
than a stab in the dark. It is important to put that point on the
record.
I am sure
that the Minister has listened to the exchange with genuine and sincere
concern, and will give a detailed assurance on the matter when he
addresses the issues. It is important for him to reconcile the cost
differences between the regulatory impact assessment and the
Financial Times report, and the point raised by my hon. Friend.
He also needs to explain how those costs were reached given that the
work of the CQC is yet to be defined.
The Government say that in the
long term, the merger will save £60 million per annum. The CSCI
is concerned that the CQC will be on a challenging financial footing
from the outset—most of us might accept that that is the case
with every organisation.
None the less, it will be challenging for the CQC, because the CSCI has
already had that experience. I mentioned earlier that it has already
demonstrably met its targets to trim costs and it should be publicly
congratulated for doing so in a graded way. It is always difficult to
pare down running costs, which it has managed to do without standards
or the scope of its activities suffering. It is particularly concerning
that, as some of the powers for the new commission are permissive
rather than mandatory, the CQC may not be able to allocate funds to
permissive powers. The Minister has confirmed that the wind-up costs
will now amount to about £140 million. Will the Minister confirm
those wind-up costs—clearly an important sum to
understand—and, most important, tell us when the £60
million of savings will be delivered? What is the projection for that
and how will they arise, not least by not impacting on the scope,
quality and delivery of services?
I will now provide a final
round-up of the amendment. It is with some apologies that I take time
over it, but I hope that it sets the scene for an important amendment
that would help to encompass so much more of what we are trying to
achieve early on in our deliberations. Part of the impact of the
amendment would be to mitigate the impact of the upheaval of further
change and regulation. The Minister accepted, during the course of his
oral evidence this morning, that there is inevitably some disruption
when there are changes such as this. He said that we have to weigh up
the benefit of going through the process against the inevitable
disruption that we have to suffer. We have changes in the social care
regulation timeline, and I shall look at how they have
progressed.
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 Act
2003 created the CSCI, which was launched in 2004, incorporating the
social care responsibilities of the NCSC, 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 the 2005
Budget statement the Chancellor announced the merger. In his oral
evidence, David Rogers of the LGA noted:
“Organisational change
always causes some short-term disruption and some loss of focus for a
short period.”——[Official Report, Health and
Social Care Public Bill Committee, 08 January 2008; c. 82,
Q193.]
The Minister was right to
point out, in his evidence this morning, that Mr. Rogers
thought that the long-term benefits outweighed the disruption, as I
indicated earlier. However, Mr. Rogers said that everything
must be attempted to minimise the disruption and loss of focus. The
amendment would do that, but the Minister, unfortunately, has not yet
told us how he would do it, so I hope that he will find our proposal a
convenient way to short-circuit the concern that we would otherwise
have, and will accept our amendment.
If the Minister wants a list of
questions to address, perhaps I could usefully summarise the questions
that I hope he will be able to address, as well as giving us
some comments on the general arguments that I have advanced to underpin
and substantiate the merits of the amendment. Will the Minister outline
what quality inspection functions and duties the new regulator will
lose from the sum of its parts? Would it not be better for the current
regulators to be brought under one roof and one brand in the
legislation, but for their functions to remain unchanged by Parliament
at this stage and joint working delivered organically? Does the
Minister agree that the constant restructuring of regulation has been
disruptive, and will he tell us why the Government will get it right
this time, and why the Committee should give them another
chance?
Without
having information on the scope and content of registration, how did
the Minister make the cost estimates that he has made? Will he first
reconcile, as I asked earlier, the cost differences between the RIA and
the Financial Times report and, secondly, explain how those
costs were reached, given the fact that the work of the CQC has yet to
be defined? What percentage of the savings is due to organisational
costs and what to regulatory costs? That distinction is of key
significance, particularly remembering CSCI’s evidence that it
has managed to pare to the bone the organisational costs. One must be
careful in any walk of life—this certainly compares to my own
business life—not to aim to achieve things that are
unattainable. If one already asked management to reduce costs to the
bone, one does not need to start chipping away at the bone itself. That
is a recipe for disaster. When will the £60 million a year
savings be achieved?
Does the Minister accept that
there has to be some acknowledgement of, and even culpability for, this
constant restructuring, which is hardly motivating for all those who so
dedicatedly give their lives and careers to the public services that we
depend upon? With that set of arguments, I commend the amendment, and I
hope that the Minister will feel that the arguments are compelling
enough to accept
it.
1.30
pm
The
Chairman:
Order. I chose not to intervene when the hon.
Gentleman was taking an intervention from his hon. Friend referring to
a money resolution in the House next Tuesday. For the record, it is a
Ways and Means resolution not a money
resolution.
Sandra
Gidley (Romsey) (LD): I too welcome you to your role, Mr
Hood. This may be an appropriate time to declare an interest. I am a
fellow of the Royal Pharmaceutical Society and aspects of the Bill
directly influence my profession. It is easier to state that at the
outset rather than when we get into the specifics.
This is a brief amendment to a
brief clause. In some ways we have had a stand part discussion as well,
but I will seek clarification on that if necessary. Most of my comments
are general but, as this is a 161-clause Bill, I will try to avoid
repetition for the sake of it.
Liberal Members have supported
the principle behind the merger, but it is right to ask questions: why
now, when the existing the existing regulators are
starting to work extremely effectively? Is it worth the upheaval and
extra cost——and to achieve what, really? Reorganisations
are always costly, not just in money but in staff time. We all suffered
the pain of the reorganisation of the primary care trusts, where people
were demotivated because they did not know whether they had a job and
were unsure of their future role. When our regulatory system is
beginning to work so well, there are concerns about putting the brakes
on, and some things possibly not going as well as they could. The
regulatory impact assessment has been mentioned, mainly in the context
of costs. Costs are important and we all want to make maximum use of
public money, but I must stress the point raised the hon. Member for
Eddisbury.
Stephen
Hesford (Wirral, West) (Lab): As I understand it, there
was no vote on the principle of the Bill on Second Reading, so I am at
a loss as to where the hon. Lady is going in asking “Why
now?”, if the principle of the Bill has already been
agreed.
Sandra
Gidley:
If the hon. Gentleman had been listening, he would
have heard me say that we agreed in principle, but that I thought that
it was pertinent to ask those questions. Just because a principle is
agreed, it does not mean that the detail is agreed. We would not be
doing our job properly unless we ensured that whatever replaces the
current regulators does the job as well, if not better. That is a
public responsibility that we all have. We have to make sure that we
get the detail right. That, I thought, is why we were on this
Committee.
The
problem of costs has been raised, and it is not clear what they should
be. The biggest problem, as highlighted by the hon. Member for
Eddisbury, is that we do not yet know the full scope, breadth or detail
of what the new body will do. It would be useful to have more detail
when we discuss that.
I also want to echo the
concerns raised by the Member for Tiverton and Honiton about costs
being passed on to hospitals, nursing homes and other bodies. There has
been a drift in that direction to some extent already, but it is
robbing Peter to pay Paul, because in some cases those costs are just
picked up by a different part of the NHS. Some clarity on that would
help.
As well as the
costs, the regulatory impact assessment pointed out other risks. It
said that the key risks would be
“the Care Quality Commission
establishment problems; lack of
resources”—
but,
and this is possibly of more concern to most of us in many ways, there
was also
“slipping
compliance with minimum quality
standards.”
That is on
the face of the impact assessment and we are asking these questions
because I do not think any member of this Committee wants to see
standards fall or to have to deal with the consequence of
that.
The regulatory
impact assessment states that there is a risk regarding the
“Care Quality Commission
having a lack of resources to function properly; or that the Care
Quality Commission is unable to properly carry out its functions or
does so in a way that is more inefficient than under the current
system.”
I hope that the Minister for the South
West agrees that those are the very things that we seek to avoid. The
hon. Member for Eddisbury raised some pertinent questions and I look
forward to hearing the Minister’s
response.
Kelvin
Hopkins (Luton, North) (Lab): It is a pleasure to serve
under your chairmanship, Mr Hood. I declare an interest at the outset
in that I am a co-chair of the Unison group of
MPs——Unison has by far the majority of trade union
members in this sector——and I am in receipt of a Unison
pension as a former Unison
employee.
While I am
not in any way speaking in favour of the amendments, I want one or two
assurances from my hon. Friend the Minister about costs and budgets.
Clearly, there will be some economies of scale that will no doubt
reduce costs overall—a figure of 40 per cent. has been
mentioned. But there are concerns that this might put budget pressures
on the inspection system. I would like my hon. Friend to give
assurances that inspection will not be damaged by budget pressures
because, particularly as I have mentioned previously, this is largely
private sector now, especially long-term care for the elderly. It is
important that there is a rigorous inspection system to ensure that
care standards are maintained at a high level and nobody in a care home
suffers as a result of inadequate performance by the providers because
they are not being inspected. Can my hon. Friend could give some
assurance on
that?
Mr.
Bradshaw:
May I make two general remarks before moving on
to address some of the points made by hon. Members speaking to
amendment No. 1? As I said in the evidence-giving session on Tuesday,
when a new, independent, flexible and integrated regulator is
established there is always tension between the desire to get those
elements right, a desire to take as much as possible from the status
quo and the desire to be prescriptive about what that new regulator
should do in advance of its establishment. I put that tension out there
because I suspect that tension is going to run through quite a lot of
our discussions this afternoon, not only on this amendment but on
others. Hon. Members ranged widely to discuss issues such as cost and
transition, so I want to clarify them before speaking directly to the
amendment.
The reason
we did not go ahead with the integration before was that it was only
under this Government, in 1999, that for the first time we had the idea
of any kind of independent regulation of the health service and there
was still a feeling that that culture and system needed to be given
longer to bed down. The hon. Member for Romsey reminded us on Second
Reading that her party argued then in favour of integration, although
if she has not gone off the principle, she would rather have done it
then than three years thence, which is odd. But I leave that
there.
There was a
discussion about it and we reached the general view that the system we
had there needed longer to bed in. There is never an ideal time to
integrate regulators, which I accept are working extremely well and
have a very good reputation, however good the principles and however
much all of us may support the principles of doing so. There are
transitional challenges to deal with. There has been some confusion on
cost because many people interpreted the £7 million figure that
we included in the regulatory impact assessment as the total figure for
all the costed transition. That is only the figure for the cost of
establishing the new care quality commission. The much bigger figure of
£140 million, which was in the explanatory notes, is our
estimate of the transition costs, many of which are already being
realised, as the hon. Gentleman recognised in his acknowledgement of
the savings that have already been made by the existing regulators, not
the set-up costs for the new commission. The £140 million
includes the cost of redundancies, estates rationalisation and planned
reduction of the operating costs. The savings are the result of the
commitment that we have made, which we will realise through this Bill,
to reducing the costs of all public service regulation by a third and
that will mean £60 million a year. The answer to his question is
that within three years, we anticipate that we would more than recoup
the overall costs of transition, many of which have already been made,
as the existing bodies have already managed to reduce their costs
without, I think, reducing their effectiveness in any
way.
Mr.
O'Brien:
It is helpful that the Minister is going through
the costs. I think I understood him to say that some of the amounts
encompassed within his declared figures, either in the RIA or in other
figures, include costs that are already being saved or are being
incurred by the existing bodies that will be succeeded by the CQC. Will
he confirm that and help the Committee by indicating how much he is
talking about as a proportion of what to expect to save or to incur the
cost of? That would help us to know where we are on the
timeline.
Mr.
Bradshaw:
The hon. Gentleman is right. I am afraid I
cannot give him the exact figures, but I can tell him we have been
working with the existing commissions to help them achieve those
savings and that means, we estimate, that by the time the new
commission is established, the Healthcare Commission and the CSCI will
be operating within a combined budget of £145 million. We expect
the new commission to operate within the same budget. Including the
MHAC functions, that will mean a total budget for the new commission of
£151 million and that process is already well under
way.
My hon. Friend
the Member for Luton, North mentioned Unison, with whom I had a very
good session just before Christmas in which we went through a lot of
its concerns on the Bill in detail. I hope that I managed to reassure
it on most of them, but I am happy to write to him, if he would welcome
that, in more detail. I think I could even allow him to have a copy of
the letter I wrote to Unison after that meeting and the issues we
discussed. If he wants to come back to me later in this process and go
through that, I would be very happy to do
so.
My problem with
amendment No. 1 is that we are establishing a new body and the
amendment’s practical impact would be to move all the current
functions and duties of the existing three bodies lock, stock and
barrel on top of the ones we are establishing in the new one. That
would be duplicative and create a lot of
confusion. Many of the facets of the new commission’s functions
are drawn directly from existing legislation, but there are
changes.
For example,
the new commission’s registration functions build on provisions
for the Healthcare Commission and the Commission for Social Care
Inspection under the Care Standards Act 2000, but have been made more
flexible to allow for future changes in service provision. For the
first time, they cover NHS services, as a result of which those
services that have not previously been subject to the registration
requirement now will be. In addition, CSCI has said, in particular,
that the current regulators do not have sufficient powers to act
directly when they find serious failings. We are giving the new
independent regulator a range of tougher enforcement powers to enable
that to be
done.
1.45
pm
One of the
areas to which the hon. Member for Eddisbury referred that will not be
carried forward is complaints. We are not requiring the new body to
deal with second-stage complaints. Such issues have already been
extremely burdensome for the Healthcare Commission and it is much more
important that we improve the quality of complaints handling by health
care providers. I think that it was Dame Janet who said in her evidence
that that was a real mess at the moment and that it was too
slow.
The most
important thing is to give powers to the new Care Quality Commission,
as we are doing, to ensure that health care providers have proper,
decent and satisfactory complaints procedures for patients rather than
burdening the independent regulator with a second-stage complaints
responsibility. There will still be a second-stage complaint, which
will be dealt with by the health ombudsman, but we did not consider it
a good idea to burden the new regulator with such matters. We wanted it
to concentrate on its core functions of quality and
safety.
Mr.
O'Brien:
I am grateful to the Minister, not least for
having delayed giving way so that he at last referred to the ombudsman,
which is the point of my intervention. He will be aware that it has
been said on Second Reading and subsequently that, as a result of this
approach, concern has been expressed about whether the ombudsman will
have the capacity to deal with the anticipated number of further
complaints by way of the final court of appeal coming to him. It would
be helpful if the hon. Gentleman would undertake, now or later, to
ensure that we have a better handle on such matters because, for the
proposal to work well, we must have confidence that the ombudsman is
configured with the right capacity to deal with the anticipated
increase in the number of
cases.
Mr.
Bradshaw:
I should certainly welcome a discussion about
that at a later stage. I emphasise the fact that, by making the quality
of the complaints procedures of health care providers a priority for
the new Care Quality Commission rather than giving them such a
responsibility, our aim is that the quality of
complaints procedures becomes much better at provider level. That will
mean that fewer complaints will need to go to a second
stage.
The ombudsman
will be dealing with more complaints than at present, but it is
desirable first and foremost that we improve the quality of complaints
procedures at provider level. As members of the Committee know, our
constituency surgeries are full of people who consider that their
complaints have not been dealt with properly. Many times, if the
complaints had been dealt with properly by the provider, even if just
by way of an apology, matters would often not have escalated and
overburdened the Healthcare Commission. If matters are dealt with in
that way, they will not overburden the
ombudsman.
Anne
Milton (Guildford) (Con): I might have missed something,
but my understanding of the office of the ombudsman is that it cannot
investigate quality of care, but only the process. Will the Minister
clarify
matters?
Mr.
Bradshaw:
My understanding is that, if we ask the office
of the ombudsman to take sole responsibility for second-stage
complaints, it will be able to investigate them and how they had been
dealt with. That would involve quality, but I shall clarify matters for
the hon. Lady as I am not absolutely certain whether we shall change
that or whether it needs to be changed. It is something that I shall
happily clarify for her as we
progress.
Angela
Browning:
We heard in the oral evidence session that the
Healthcare Commission finds it useful to identify emerging trends that
might be the subject of a more detailed analysis on its part. Surely
that also applies to the complaints procedure. If it is now to be
divorced from the complaints procedure, emerging trends that might be a
worthy subject for a more detailed analysis and report will be lost to
it. If the office of the ombudsman does not initiate its own reports
because of emerging trends, who will plug that
gap?
Mr.
Bradshaw:
The Care Quality Commission will still have
access to trends and types of complaints, so it will still be able to
track them to see whether there are an unusual number of complaints
about a particular issue or against a particular provider, but it will
not deal with and investigate second-stage complaints itself. It will
still have that responsibility and still be able to act on that. In
fact, that will be very important. It will remain a very important part
of its job. With regard to an area in which I know she has a special
interest——learning disabilities in
Cornwall——that is exactly how the Healthcare Commission,
as it now is, got involved in its investigation there. That will not
change. It is just that it will not be burdened by the actual
investigation of the individual complaint. That will be the
responsibility of the ombudsman, if it has not been dealt with
satisfactorily, which we hope it will have been, by the original
provider. Did the hon. Member for Guildford want to intervene? We are
having an extended debate on the complaints process, Mr.
Hood, but I will take your guidance.
Anne
Milton:
Thank you for the clarification, Mr.
Hood. The reason we are emphasising this is that public confidence in
the complaints procedure is crucial, as the Minister said, for his own
postbag and for us all. Can he confirm that he will write to us to
clarify exactly what remit the ombudsman will have because my
understanding is that this will be a significant departure in the role
of the
ombudsman?
Mr.
O'Brien:
The Minister has very rightly said that he will
seek to help the Committee in relation to complaints, which bear very
much on amendment No. 1 as one of the issues we are concerned
about, and whether we will lose stuff through the gaps. He will be
aware—and it may be useful when he comes back to the Committee
to make sure that he gives a complete response to us and to think the
issues through—that about 7,000 complaints a year are dealt with
by the Healthcare Commission. Can he confirm the current backlog, for
which, I understand, anecdotally, that estimates range between 30,000
and 80,000? Perhaps that will help by giving us a handle on what the
capacity issues for the ombudsman are, even taking into account the
improved quality of process. What about complaints in relation to
privately funded social-care
users?
Mr.
Bradshaw:
I will come back to the hon. Gentleman, as I
said, but I think he helps make my point: our prime concern is to
improve the quality of complaints-handling at provider-level in order
to avoid this burden and to improve patient satisfaction.
Having a good complaints
procedure and making senior managers of providers responsible for the
quality of that complaints procedure will be a requirement of
registration under the new Bill and the new regulator will make sure
that that happens.
This direction of travel has
been welcomed by patients’ groups, who share our frustration
that the current system complaints-processing is not satisfactory, by
and large. There are some very good examples of good practice but I am
afraid that that does not apply throughout the piece.
I shall turn to some of the
other questions raised by the hon. Member for Eddisbury, particularly
on visits. He asked about visits both in the context of MHAC and CSCI
and I reassure him—this was raised by MHAC in its evidence on
Tuesday and on Second Reading—that visiting powers are retained
in the Bill as far as the existing visiting powers of MHAC are
concerned. Schedule 3(8) proposed new section 120(3) states that
it
“must make
arrangements...to
visit”.
Although
I am reluctant to try to put the new regulator in a straitjacket in
advance, we envisage that, in areas of particular concern to MHAC,
visits would continue with their current regularity.
I return to a question raised
by my hon. Friend the Member for Luton, North. On Tuesday, even Sir Ian
Kennedy, in critical mode, said that one of the areas of the Bill that
he was prepared to openly support was the idea of modern, precautionary
and risk-based regulation. That includes not having a straightjacket
where someone has to visit every institution once a year, every six
months or even every 18 months, but instead, having a visiting policy
that can be based on an assessment of risk. Facilities or institutions
that are a greater cause of concern can be visited more regularly than
those that have held an exemplary record for a number of years. Spot
checks can be made whenever required, and so forth. It is important to
allow the new regulator to build on that process, rather than trying to
put them in a straightjacket in advance.
Angela
Browning:
On that point, we were given a specific example
yesterday with regard to the Mental Health Act Commission implementing
the Mental Health Act. For example, when an inspector goes into a
secure unit to do a mental health inspection, sometimes they come
across things that are happening to patients who are not detained under
the Act against their will, but who are there as voluntary patients.
The example was given of somebody tied into a chair who, because they
were a voluntary patient and not sectioned, the inspectors could do
nothing about. Does the Minister intend to amend the Mental Health Act
and to extend the scope of that
inspection?
Mr.
Bradshaw:
My official is shaking her head, but I
understood that one of the things that MHAC welcomed about the Bill was
that its provisions would allow the commission to take action if it
came across a similar case. We may not need to amend the
Bill.
Sandra
Gidley:
I want to pick up on the risk-based assessments
and visits, which I think are a worthy principle. However, we need to
take account of situations where a nursing home, which previously has
had a good record, has a change of hands. I have seen some dramatic
changes after a change of hands.
Mr.
Bradshaw:
I agree. A change of management could be a
trigger point for the new regulator to want to carry out an inspection.
However, it is not something that we need to prescribe—they will
be the experts.
Kelvin
Hopkins:
This is a specific comment on my earlier remarks.
My point was that, whatever the inspection regime, if there are budget
pressures, there is a temptation to reduce the level of front-line
work. To take a distant parallel, when water was privatised, many water
authorities immediately cut their inspections to save costs—it
rained a lot and they did not need to worry about leaks. I do not
suggest that there will be immediate cuts, but budget pressures clearly
impact upon the level of service that can be provided. There are
inherent dangers if that is not specified.
Mr.
Bradshaw:
I am sure that my hon. Friend is as happy as I
am that we are not privatising anything under this Bill. I recognise
the danger, and I assure him that the last thing that we want to do in
setting up a new regulator, is to create the risk that in five or 10
years we will face horrendous headlines of scandals,
which could have been avoided, because of what we have done. The savings
that we are talking about—I hope the hon. Member for Eddisbury
who asked the question will forgive me, I do not have the specific
ratio—will be made, for example, by the amalgamation of
back-office functions or a reduction in duplication. Some of the new
inspection procedures and policies that existing organisations are
undertaking, have already led them to make most of the savings that
they needed to, in time for the integration of the three agencies. I
suggest that, unless he has evidence to the contrary, as far as I am
aware, that has not led to any serious problems in inspection or
resulted in a lack of inspection. I hope to reassure my hon. Friend the
Member for Luton, North on that.
On the ratings question that
the hon. Member for Eddisbury asked, the quality ratings that the CSCI
does will be able to continue under the legislation, and we anticipate
that they will. Again, that is not something that we are laying down
the law about, but that is certainly our
expectation.
2
pm
I want to make
the point that I made before about integration. As health and social
care provision become increasingly integrated, it may not be obvious,
or even meaningful, to the new commission whether it should be
following its functions and duties for health as the current Healthcare
Commission or Mental Health Care Act Commission, or those for adult
social care as the current CSCI. That is why, rather than transferring
them lock, stock and barrel in their current legislative form, as the
amendment recommends, we are creating integrated functions for the new
commission. The amendment, rather than protecting the current
provisions, would lead to fragmentation and confusion within the new
commission. It would unbalance the coherent provisions that we have set
out in the Bill and detract from its purpose. I hope that the hon.
Gentleman will agree to withdraw it.
Mr.
O'Brien:
I am grateful that the Minister has sought to
take seriously the issues that we have raised. I note, with some
enthusiasm, that he has undertaken to burn a bit of midnight oil to let
the Committee have more information on some specific areas that we have
identified.
I am
concerned that it was a long introduction, but it did cover a lot of
points. Hon. Members on both sides of the Committee have found it
important to raise those important issues about transition, where so
many of the questions are arising, as well as some of the more focused
points, which no doubt we will come on to in our
deliberations.
In
light of what the Minister said, it would be false to suggest that I
feel either completely assured or satisfied. I dare say that those who
observe our proceedings from outside will be concerned that the measure
does not necessarily give us more of a handle on how this is all going
to happen, or provide the safeguards. I am also concerned that we have
not necessarily bottomed out all the costings, which would have helped.
The Minister was reintervened upon before he had the chance to say that
he had tried to put
in the Library the estimates and the costs. Perhaps some savings have
been secured before the CQC comes into existence. That may be
information that he would like to share with the Committee. He gave us
some assurance on the record, but if there were a possibility of
showing us some of the financial information as regards the figures in
the regulatory impact assessment, that would help us to understand
where the flow of moneys is and what is already being worked on by
those, as he rightly says, admirable and high-quality working bodies
that will be succeeded by the CQC, which will then be challenged to
make further organisational efficiencies without sacrifice to
services.
It is with
those thoughts that I think that it is appropriate to withdraw the
amendment. In addition, I think that a lot of these matters will be
reconsidered during the passage of the Bill. I beg to ask leave to
withdraw the amendment.
Amendment, by leave,
withdrawn.
Clause 1 ordered to stand
part of the
Bill.
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