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Session 2007 - 08 Publications on the internet General Committee Debates Health and Social Care Bill |
Health and Social Care Bill |
The Committee consisted of the following Members:John Benger, Celia Blacklock,
Committee Clerks
† attended
the Committee
Public Bill CommitteeTuesday 15 January 2008(Morning)[Derek Conway in the Chair]Health and Social Care BillFurther written evidence to be reported to the HouseH&SC 21
Commission for Social Care
Inspection
H&SC 22 Geoffrey
Crittenden
H&SC 23
BLISS
H&SC 24
Which?
H&SC 25 Local
Government Association
10.30
am
The
Chairman:
Good morning. Before we start, I would like to
inform the Committee about arrangements for this afternoon. Members
will have noticed that there is a debate on the Floor of the House on a
Ways and Means resolution relating to the Bill, which will start at the
beginning of public business. Mr. Hood and I propose that
the Committee resume its consideration 10 minutes after the conclusion
of the debate and any Division. If the Committee is content with that,
it seems a sensible way forward.
Mr.
Stephen O'Brien (Eddisbury) (Con): On a point of order,
Mr. Conway. When we resume 10 minutes after the
debate—at whatever time that is, depending on whether there is a
statement—will we have the same amount of time that we would
have had: in other words, will the time be effectively sheared, not
truncated?
The
Chairman:
We do not know when the Ways and Means
resolution will be taken this afternoon. The ten-minute Bill may be
divided on or there may be Government statements—it is beyond
the control of the Committee. On when the Committee adjourns this
evening, as there is no knife set for today it will be for the
Government Whip to move the Adjournment, and I am sure that that will
be discussed in the usual way. If the Committee sits very late, it
remains within the power of the Chairman to suspend for a break, but
the Committee itself will decide when to
adjourn.
Clause 2The
Commission’s
functions
“without
prejudice to the activity and independence of the
Commission”.
The
Chairman:
With this we may discuss the following
amendments: No. 4, in clause 2, page 2, line 22, leave out
“direct” and insert
“advise”.
No.
5, in clause 2, page 2, line 22, at end
insert
“4(A) The
Commission shall not be bound by advice given under subsection
(4).”.
Mr.
O'Brien:
It is a pleasure to resume our proceedings
under your chairmanship, Mr. Conway. Amendments Nos. 3, 4
and 5 to clause 2 make up a crucial area of consideration. Members
across the Committee will recognise that the clause establishes the
vital principle as to whether the Care Quality Commission will be, in
mind and spirit as well as the letter of the law, truly independent as
a Government body, or whether it will effectively be a creature of
Government and feel that it owes its fealty to the Government and
Ministers.
For the
convenience of the Committee, I will address all three amendments
collectively as they apply to the same point, and I ask members of the
Committee to look at the way that they work. The focus should be on
amendment No. 4, which seeks to leave out the word
“direct”, and insert “advise”. It means
that clause 2(4) would
read:
“In
performing its functions the Commission must also have regard to such
aspects of government policy as the Secretary of State may
advise”,
rather than
“direct”.
I am sure that everybody
recognises that there is a massive difference, in terms of
independence, between being directed to do something and being advised
about the Government’s view and what they would like to see
done. The latter leaves genuine discretion for an autonomous
body to arrive at its own view independently, and to be accountable for
the decisions that it makes. I hope that in taking the amendments
together, they will be seen somewhat holistically, although the
emphasis is on amendment No. 4 for this purpose.
The debate
on independence relates not just to the CQC; it is threaded throughout
the Bill, and the background shows that the Government have power over
appointments, reviews, direction, funding and the secondary legislation
concerning this so-called independent regulator. The
Government’s unwillingness in this regard is obvious, and we
need to tease out from the Minister why they are unwilling for the Bill
to set out a general function for the regulator—or, indeed, to
consider the patient voice—yet they have set out their own power
of control over the regulator. We clearly have as best a clue as we can
get as to the mind of the Government. They intend to ensure that
prescribing their power over the regulator is set out in the Bill, but
not the general functions for the regulator. Nor is consideration given
to the patient voice—an issue that has been of vital interest
throughout the House for many years, and which has been the subject of
amendments tabled by Conservative, as well as Liberal Democrat,
Members. I hope that the Government will listen carefully to my
arguments and not take it amiss when I say that they seem unsure of
themselves. It is baffling how they have come to be in such a position
in respect of independence for the NHS and its associated
bodies.
In his widely reported personal
new year message to the NHS, the Prime Minister
said:
“We will
also examine how all these changes can be enshrined in a new
constitution of the NHS setting out for the first time the rights and
responsibilities associated with an entitlement to NHS
care.”
I am sure that
Members will recall that that was said on 1 January this year. However,
in the society section of The Guardian on 7 January, the
Secretary of State for Health, the Minister’s immediate boss,
submitted that the constitution will not enshrine the rights of
patients. The newspaper reported:
“Johnson discloses that
he does not want the constitution to be enshrined in legislation. That
could give patients rights they might seek to uphold in court.
‘I don’t want the constitution to give lots of work to
the lawyers so that the NHS spends more time in court and less on
treating people’, he
says.”
It would be
difficult for any of us to disagree with that, but it flies in the face
of precisely what the Prime Minister said on 1
January.
The
relevance of this issue goes to the heart of what is truly intended to
be the definition of independence, as structured by way of statute,
that we are contemplating while discussing the amendment. We want to
make sure that we understand how the Government can get away from
feeling that they must have the power to intervene and meddle, without
giving corresponding protection to the independence and autonomy of the
body that they want to create under the
Bill.
In her
evidence, Dame Denise Platt
said:
“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...I am not sure that the Bill presents
that sort of independence. There are a lot of references to
‘with the agreement of the Secretary of
State’.”——[Official Report, Health and
Social Care Public Bill Committee, 8 January 2008; c.
14.]
That comment came out of a
situation that is the reverse of what is happening now, which is that
the Care Quality Commission should not have to seek the agreement of
the Secretary of State before undertaking special reviews. We shall
come to that later in the
Bill.
To make sure
that I am making myself absolutely clear, I shall highlight the best
example of special reviews, which has been already cited in Committee.
The old community health councils, which were independent and had
authoritative power, respect and trust, used to amalgamate collectively
evidence from all their various inspections in order to publish their
bedwatch report. It meant that people knew whether we had the capacity
and whether the beds were available. The report was trusted because it
was independent, and it is clearly the sort of thing that we have in
mind to ensure independence from the
Government.
Let us
consider what would happen if, under the power to
“direct” rather than “advise”, a Government
did not like the fact that some valid, truthful, evidence-based
revelations or comments came out about certain aspects of the health or
social care settings at an inconvenient moment, perhaps in the run-up
to local elections. It surely would not be in the best interests of the
patients if the Government could use clause 2(4) to direct that the CQC
was not in a position to publish what it might wish to publish, or to
initiate what it might wish to initiate. That goes to the
heart of whether we are dealing with an intention to establish an
independent body, or whether this is just a cloak for trying to manage
bad news, from a Government who do not want to be criticised.
I hope that the Committee will
take its role seriously, and that it looks at its proper scrutiny
function as a Committee in challenging the Government. I hope that I
can appeal beyond the normal partisanship and ask Government members of
the Committee to give serious consideration to what is truly meant by
independence, given that that is what is proclaimed and given the
experiences that we have all had, as Members. Trust and confidence in
these areas is dependent on whether the body being created is
independent of the direction of the Secretary of State and his
Ministers.
Having
quoted Dame Denise Platt’s forceful comment in the evidence
sessions, at which we were all present, I find it interesting to note
that while she said that the CQC should not have to seek the agreement
of the Secretary of State before undertaking special reviews, the
converse is also true. The Secretary of State should not be able to
direct the limited resources of the CQC to a particular
issue—let us call it issue X—that may be in the political
interests of the Secretary of State. I doubt whether any Labour member
of the Committee would particularly welcome that if there were a change
of Government and, therefore, a Secretary of State in the cause of a
Conservative Government. I imagine that in those circumstances, they
would make equal criticism of the concept of that
possibility.
Equally, the converse is true
when the commission believes that it should look at issue Y, and that
it is more in the interests of patients, service users and health and
social care practitioners than the Government perhaps want the CQC to
emphasise. The regulator should be driven by the needs of health and
social care services staff, patients and users, not by the exigencies
of political life. Despite the fact that we are all political animals
and partisan in many ways, surely each and every member of the
Committee recognises that that would be a wholly irresponsible way to
proceed in order to promote the exigencies of party political life.
With such power in the hands of the Secretary of State through the
Bill, the temptation to misdirect or meddle with the work of the
regulator for a particular political gain is high. We are in danger of
passing a law that could give a licence to that political gain
judgment, which, I am sure, taking our duties responsibly, is
inevitably something that we would all wish to avoid.
In its submission, the
Healthcare Commission—it was speaking to clause 41, but the
point is wholly relevant here—stated
that
“there is a risk of
conflict with the independence that the Bill envisages for the
regulator.”
In addition,
it does not think that
“the Government should determine
operational priorities for an independent regulator.”
Clause 2(4) effectively gives the
Secretary of State that ongoing power. Perhaps the Minister will stand
up shortly and say that the word “direct” is intended
only to indicate the broad thrust of what the Government want to see
done. That is not what the Bill states.
Anybody thinking correctly would be minded to think that
“direct” means to direct right down to the level of
operations.
We have all had various
examples, going back 20 or 30 years in all of our political memories,
as to whether “direct by a Secretary of State or a
Minister” would include, for instance, the recommendation or
direction that somebody at the top of an organisation that is intended
to be an independent, arm’s length or a non-governmental
departmental body should be sacked. Should we continue with the wording
in the Bill, there is nothing to stop the Secretary of State from
directing that the CQC should sack somebody.
Does any member of the
Committee think that that is the right way to proceed? Does anybody
think that the operational meddling that that would entail, let alone
the political backlash that would no doubt follow from it, would be at
all appropriate? Should members of the Committee allow that measure to
pass through?
I
appeal particularly to those on the Government Benches to give the
issue the serious consideration required. We are dealing with the
essential element of trust. It is not just that we are talking about
trust in general, which would be appropriate for a Second Reading
debate. Clause 2(4) uses the precise words “may direct”.
I am not persuaded by the use of “may”—and the
argument that, in other words, the Secretary of State may
not—because the truth is the clause gives the Government the
power and that is what they want. We need to ensure that the
Government’s powers are properly checked. That is our duty and
the amendment gives us the opportunity to ensure that the clause refers
to advice rather than
direction.
10.45
am
Let me be
blunt: people remain suspicious, and it is not just me—perhaps
it is inevitable that as representatives of political parties we have a
political view on the matter—but many people in the health and
social care field. When preparing for the Committee, those people have
said that they fear, and feel, that Ministers have perhaps concluded
that they will find it more convenient if criticism of anything to do
with the NHS and the social care field is effectively shot down. They
have also said that the Government used to feel they had a monopoly or
some kind of political purchase on those matters and that is now
shifting. Whether or not that is true, it is wrong for us to enable
people to feel that they should distrust Government to that degree. The
wording of the clause would clearly perpetuate that belief. Therefore,
I hope that the Minister will seriously consider the
amendment.
I also
note that the covering letter of the Healthcare Commission’s
submission states that the
“regulator should play a central
role as an independent provider of reliable information allowing for
local and national comparisons to support decision-making by patients,
commissioners, providers and
Government”.
I think
that everyone would say, “Hear, hear” to that. However,
we would be concerned if authoritative, independent and trustworthy
information were provided on the bedwatch scheme, for example, and the
Secretary of State suddenly directed the CQC to have regard to the
aspects of Government policy that he or
she—it may be a she in future—wishes it to. It may be that
the Secretary of State does not want certain types of evidence to be
put into the public domain at a particular time and that he or she can
issue a direction to shut the CQC up. In terms of democratic
accountability that is inappropriate.
If the Secretary of State
said, “Look, I advise that it would be very unhelpful to put
such information into the public domain and you ought to reflect
whether this is an appropriate moment to do so”, I am sure that
the fact that the Secretary of State picked up the phone to say that to
the head of the CQC would have a powerful effect. Whoever is the head
of the CQC is bound to listen carefully to the Secretary of State, but
it should at least be the chairman of the CQC’s decision whether
or not the Secretary of State is making a valid point that is
appropriate. It should also be their decision whether it is in the
public interest to withhold information rather than being
simply commanded to do so from on high because it is politically
expedient.
I
seriously hope that the Committee does not think that we are having yet
another rather indulgent debate along party lines. This issue goes to
the very heart of our duties as Members of Parliament, and many people
from outside—I recognise that Committee proceedings are not
heavily reported in the outside world—think that the issues of
trust and independence do have traction. I hope that each and every
Member will think seriously about the amendment and come to a
favourable
decision.
During the
oral evidence session that was held earlier in the Committee’s
proceedings, the Minister left hanging the question. He
said:
“there may be an
inconsistency between their
desire”—
the
witnesses—
“for
more prescriptiveness on the face of the Bill and their desire for the
new commission to be flexible and
independent”.
I think
that we understand that and are sympathetic to it. Anna Walker from the
Healthcare Commission immediately responded to that point,
saying:
“In
certain instances, we do not believe that framework is right
yet.”——[Official Report, Health and Social Care
Public Bill Committee, 8 Jan 2008; c.
12-13.]
A stronger statement of
purpose supported by the main stakeholders and Parliament would not
constrain the new commission, but it would constrain the invasive power
of the Secretary of State. The amendment would avoid the Secretary of
State being over-prescriptive, which is the very sentiment that the
Minister tried to assert in his oral evidence, but from the point of
view of the creature created by the Bill—the CQC—having
that set of prescriptions placed upon it.
Let us avoid throwing stones
in glasshouses and ensure that the Minister is aware that it is
incumbent on Government to live up to the evidence and phraseology that
he used in his own oral evidence during the Committee’s first
sessions. The Minister is confusing independence, which is necessarily
defined in relation to other bodies, with freedom. While the commission
should be given the necessary freedoms to determine the scope and
nature of its regulation, it is our job, as parliamentarians to
prescribe the limit within that scope—a point that the Minister
has hinted that he will
make when we come to the discussion on cosmetic treatment. I know that
Liberal Democrat Members are also concerned about that. I dare say that
he might already have thought about the amendments on cosmetic
treatment and surgery, and might have already decided to reflect them
in separate changes. We will wait and see.
Dame Denise Platt, from the
Commission for Social Care Inspection, also noted in her oral evidence
that, while leaving everything to regulation is the ultimate
flexibility, it is also the ultimate straitjacket, because it depends
on how the Secretary of State frames the legislation. That is the nub
of the issue. There is no way that we can be assured that the Secretary
of State will not be the ultimate prescriber, while he retains the
power to direct. We are looking here at the vital and fundamental
question of whether the Bill is a genuine one that is going to deliver
on what it proposes, or whether it is effectively a prescription by
Government, laid upon the bodies that it creates as ostensibly
independent, which will come under the potentially great clunking fist
of this Government.
The Minister was very occupied
with ensuring
“democratic—that is,
public—accountability the more distant an independent body is
from any governmental oversight or
control.”——[Official Report, Health and Social
Care Public Bill Committee, 8 January 2008; c. 49,
Q96.]
That point was made with
reference to the Office of the Health Professions Adjudicator in part
2, but the principle and sentiment are relevant to the Care Quality
Commission in part 1. Given the weakness in the clause of any direct
appeal to groups within the demos, it would be a difficult point for
the Minister to contend. Is he unhappy with democratic accountability
stemming from Parliament? Democratic accountability, in some terms, is
the measure at the ballot box of the independent bodies that the
Government have set in motion. We can draw on the example of
the independence of the Bank of England, which the Government have
always been proud of. Let us use the very independence that
they have sensibly proclaimed as their best model here as well. Why
not?
The Minister
may want to show his good intentions this morning—I very much
hope that he does—and the recognition of the value of true
independence by withdrawing the subsection. We have made it clear that
this is an important debate, and I hope that all members of the
Committee will now feel that they can spend the rest of the morning
debating the issue, as it is vital to the Bill. I am perfectly happy to
work hard and to stay as late as necessary. The important point is to
flush out whether everyone is truly in agreement with this, or realises
that some fundamental issues are at stake for us all. The Minister has,
therefore, a number of questions, which I shall briefly set out, and
that will be the way to get the debate genuinely in front of him.
Why
is the Minister unwilling to grant full independence to so many of the
bodies in the Bill, not least the CQC? Does he agree with the Prime
Minister that independence should be achieved by enshrining a new
constitution for the NHS, or does he agree with the Secretary of State
for Health, who does not want such a constitution enshrined in
legislation? What assessment has the Minister made of the concerns of
the Healthcare Commission and the Commission for Social Care Inspection
that the Bill does not provide the necessary independence? What
impact on public faith in the regulator does the unfettered residual
power of the Secretary of State over the commission have? It is
unfettered under the clause. Does the Minister agree that a closer bind
on both the extent and the content of the Secretary of State’s
secondary legislative powers actually constitutes greater, not less,
independence for the commission? Can democratic accountability come
only when a body is not independent of Government, and consequently,
party politics? What guarantees can he give that clause 2(4), as
currently drafted, will not lead his Secretary of State, and future
Secretaries of State of any party, to direct the commission according
to political expediency?
With these amendments,
particularly amendment No. 4, we have a real opportunity to improve the
Bill, to improve and make clear the Government’s intent, and
above all, to give truth and earnestness to what the Prime Minister
proclaimed on 1 January.
Greg
Mulholland (Leeds, North-West) (LD): There is concern
about the clause, as I am sure that the Minster will accept, and about
the fact that it appears to some, including Opposition Members in the
Committee, to diminish the independence of the Care Quality Commission,
when compared to the current situation with the three regulators. That
is the key point, and the Minister needs to justify why we are moving
away from the current situation, which is generally regarded as working
well and where the three current regulators are clearly recognised as
independent of the Secretary of State and the Department of
Health.
The Minister
will also recognise that to have the genuine confidence of Members in
the House, the medical profession and, most importantly, patients and
the general public, the new Care Quality Commission must be seen as a
truly independent regulator. That is what we want to hear in this
debate because, as he is aware, people feel that we are moving towards
a system of having more of an arm’s length regulator.
There is a lot of concern
about the word “direct”, and that is the substance of the
debate on amendment No. 4. “Direct” is a prescriptive
word and, certainly among Members on the Opposition Benches in the
Committee, causes some concern. What does “direct” mean?
What powers does it give the Secretary of State? Will there be a
situation in which the work of the Care Quality Commission can be
affected, directly or indirectly, by Ministers or Department officials?
It seems sensible for clause 2 to lay out the clear functions, powers
and role of the new Care Quality Commission, and to enshrine the clear
independence of the new body that is essential to its working.
The Minister must do a convincing job. Opposition Members are minded to
support the amendment, and we look forward to hearing what the
Minister has to say.
Kelvin
Hopkins (Luton, North) (Lab): My concern about the
amendment is that it puts a distance not only between the Government
and the sector but between Parliament and the sector. I am concerned
about the democratic input. For example, if the commission were seen to
be more sympathetic to the private care sector than I thought
appropriate, I would want Parliament and MPs to have much more say in
what happens. If it is entirely independent, the Government can wash
their
hands; if it is not independent, the Government are
still accountable to Parliament. Accountability to Parliament has not
been as strong as it should have been in recent years, and I am looking
forward to a much stronger input from the legislature rather than the
Executive.
An analogy
has been made with the independence of the Bank of England—I am
one of those people who were deeply sceptical about the idea in the
first place, and I apologise to my hon. Friends who might take a
different view. However, I am sceptical, and I believe that if, for
example, the Monetary Policy Committee started to diverge strongly from
what the Government wish on interest rates, the Government would
quickly make it less independent, and could effectively take back
control at short notice.
Mr.
O'Brien:
I understand the hon. Gentleman’s point,
but does he feel—using the example of the Bank of England, which
is a sensible and useful analogy—that it is appropriate and
right for the Government to seek to take back the powers because of the
exigencies of a particular set of circumstances or declared behaviour?
Alternatively, as most would agree, should they look more carefully and
rigorously at the remit, and at what is within their powers and what is
not, particularly when trying to meet a range of inflation
goals?
Kelvin
Hopkins:
I thank the hon. Gentleman for his intervention,
but I believe that the Government should be accountable to elected
Members. The more distant these important bodies become from
Parliament, not just Government, the less democratic input there will
be. On the Monetary Policy Committee the Government, even now, have the
right of appointment and they are careful about whether they appoint
hawks or doves to the committee to ensure that they get the right kind
of answers. This much vaunted independence is not anything like as
independent as we would like to think. I am expressing doubts, I am not
necessarily condemning the amendment outright, but I want to ensure
that parliamentary accountability is retained and that ultimately, we
can have a say, as Members on behalf of the people who elected
us.
11
am
The
Minister of State, Department of Health (Mr. Ben
Bradshaw):
The Government stand accused of
confusion on this issue, but I suggest that it is the hon. Member for
Eddisbury who is confusing two things: his party’s express
desire to set up a new, big, bureaucratic, unelected and unaccountable
national quango to run the NHS—although if one believes recent
press reports, his leader is about to flip-flop on that policy as
well—and the desire that we all share for a robust, strong and
independent regulator of health and social care. I also remind him that
there was no independent regulation of the NHS before this Government
introduced a system in 1999. The Government are committed, through the
Bill, to making that system not only more robust, but even more
independent.
I will quote
from the existing legislation. The wording that we use in the clause is
exactly the same as the existing wording in the legislation. I do not
think that any hon. Member has so far suggested that either the
Healthcare Commission or the CSCI is not independent
enough. Section 130(1) of the Health and Social Care (Community Health
and Standards) Act 2003
states:
“In
exercising any of its functions the CHAI must have regard to such
aspects of government policy as the Secretary of State may
direct.”
Section 131(1)
states:
“In
exercising any of its functions the CSCI must have regard to such
aspects of government policy as the Secretary of State may
direct.”
That is exactly
the same wording that we are using in the Bill. I also note that at an
evidence taking session, Anna Walker talked about the freedoms to
conduct general reviews. She
said:
“The
Bill, in a very welcome way, has a power to carry out investigations,
and we have carried out a number of significant
investigations”.——[Official Report, Health and
Social Care Public Bill Committee, 8 January 2008; c. 17,
Q25.]
The point that she went
on to make was not about any restrictions to the CQC’s freedoms
to conduct reviews or investigations but was about her concern that
those reviews and investigations should be able to cover commissioning
as well as provision. That is a view with which I have considerable
sympathy and I think that the Bill addresses it, but we will no doubt
debate that in another place. Her concern was not about freedom to act
independently, but the remit and the scope of that freedom to cover
commissioning as well as provision.
Mr.
O'Brien:
Does the Minister therefore recognise that the
Secretary of State would have the power, under the clause, to prevent
the commission from publishing anything that it had
initiated?
Mr.
Bradshaw:
Absolutely not. I do not accept that whatsoever.
The power written into the Bill is exactly the same in the current
legislation, which is “must have regard to” and
“may”. That does not mean to say that the independent
commission has to obey diktats from the centre; on the contrary, that
would be against everything that the Government have stood for since we
introduced independent regulation in the first place. As I said, the
power as drafted does not mean that a Secretary of State is either
obliged to direct the commission to take account of Government policy,
or that the commission would have to obey diktats. However, it would
allow the Secretary of State, as the existing legislation does, to
ensure that the independent commission operates within the context of
Government policy.
I
will take the example of the NHS, a health system with massive policy
input—unlike the Opposition, we do not believe that it
should be run by an unaccountable, unelected independent quango. In
carrying out its work, it would be inappropriate for the commission not
to have regard to the nature of the NHS and the demands placed on the
public, both directly and through the political process. Clause 2(4)
provides the opportunity for the Secretary of State to require the
commission to take into account key policy areas when undertaking its
functions. It is important that the various demands of a system that is
spending more than £100 million of taxpayers’ money a
year are accountable in that way. It is a sensible precaution to ensure
that the public have faith in the accountability of both the system and
the inspection system, and that it is not undermined by
confusion.
Jeremy
Wright (Rugby and Kenilworth) (Con): Given that subsection
(3) sets out a list of other matters to which the commission must also
have regard,
including
“views
expressed by members of the
public”
and the level of
satisfaction of members of the public, does the Minister really need
subsection (4) to reinforce that point? Furthermore, does he think that
it is right for the commission to have equal regard, according to the
Bill, to those matters set out in subsection (3) and the
Government’s policy under subsection
(4)?
Mr.
Bradshaw:
The hon. Gentleman makes the point that I was
about to make in response to the hon. Member for Eddisbury. Although
not strictly related to the amendments, the hon. Member for Eddisbury
made reference to involving the public and their views. The hon. Member
for Rugby and Kenilworth has now helpfully drawn the Committee’s
attention to the fact that those issues are included in the functions,
as is the importance of the new commission having regard to aspects of
the Government’s policy. That is nothing new and is nothing that
will compromise the independent action of the Healthcare Commission. As
the hon. Member for Eddisbury took some time in speaking to the
amendments, it might be helpful if I remind the Committee exactly in
which ways the commission will be independent and is at the moment.
The
new commission must determine the criteria that provide access for
compliance with all registration requirements; it must decide whether
services meet those requirements and it must determine what action is
necessary. It will also have to establish its organisational structures
to determine what committees it requires and to develop the performance
assessment criteria, and a whole range of responsibilities that the
existing Healthcare Commission carries out excellently and completely
independently of the Government.
Angela
Browning (Tiverton and Honiton) (Con): I wish to give the
Minister an example of when the two issues come into conflict.
Subsection (3)(a) refers
to
“views expressed by
members of the public about activities to which the functions
relate”.
I
endorse the current view of the public from personal casework
concerning very elderly people who are transferred from a general
hospital to a small community hospital. They are clearly at the end of
their life and, in some cases, relatives have been told that the
patients will die within a week or two. However, relatives are still
asked to move the patients out of the community hospital and to find a
nursing home for them. I share the strong public view that is held
about that.
If the
commission thinks that that approach is inappropriate having listened
to the views of the public, but, as seems to be the case, the Secretary
of State deems under subsection (4) that people must be moved on
quickly, we immediately have a conflict of interests in an area where
the commission is perhaps best placed to know what is the appropriate
process to follow.
Mr.
Bradshaw:
The commission will be entirely free to launch
an investigation into anything that it considers is jeopardising public
safety or quality of
care and, if necessary, to launch a broader investigation into such
matters. I must say to the hon. Lady that it would be surprising if the
Government were deliberately pursuing a policy that put people’s
safety and lives at risk. If the Healthcare Commission thought that
that was the case from evidence based on the ground, it is absolutely
clear from the Bill that it would be entirely free to investigate
matters. The two priorities that we are giving the Care Quality
Commission are the protection of patients’ safety and the
quality of
care.
Angela
Browning:
The example that I have just cited is not about
putting patients’ lives at risk, but taking a humanitarian
approach to people in their final weeks at the end of their lives.
Criteria in respect of putting people’s lives in jeopardy would
not apply, but what does kick in under my example is
money.
Mr.
Bradshaw:
Well, the issue to which the hon. Lady referred
would still come under the auspices of the quality of care, if not the
safety of care. It would also come under the function outlined in
subsection (3)(d) on vulnerable adults. If the people to whom she
referred are elderly and sick, they are by definition
vulnerable.
The
clause is important to ensure that the commission does not place
competing unfair or contradictory expectations on providers of health
and social care services. While there is no obligation on the Secretary
of State to make use of the clause, having it available under existing
legislation will ensure that the commission considers the policy
context when carrying out its functions. I therefore ask the hon.
Gentleman to withdraw the amendment.
Mr.
O'Brien:
Along with other members of the Committee, I have
listened carefully to the Minister. He seems to agree with his
Secretary of State, rather than the Prime Minister, about what should
be enshrined as the rights and responsibilities of the NHS and has thus
not dealt with the issue raised by my hon. Friend the Member for Rugby
and Kenilworth who, having gone through the various provisions under
subsection (3), did not receive an answer about why the Government
still needed subsection (4). Having sought to pray in aid subsection
3(d) as a defence to why he would not commit his Secretary of State to
using the powers granted under subsection (4) in response to my hon.
Friend the Member for Tiverton and Honiton, he said without much of an
argument in support that subsection (4) would not be used to send out a
diktat to the
CQC.
The Minister
might say that now, but the rest of the world will not have been
listening to our proceedings and will not necessarily know what has
been said. What they will do is to read the words set out in the Bill.
However much he prays in aid that such words were used in the
precursors, our job is to look at the words as published in the Bill.
The hon. Gentleman’s answer
was wholly unsatisfactory. It leaves the Secretary of State with the
power to issue those diktats in the particular circumstances outlined
by my hon. Friend the Member for Tiverton and Honiton. I want to press
the amendment to a
Division.
Question
put, That the amendment be
made.
The
Committee divided: Ayes 7, Noes
10.
Division
No.
1
]
AYESNOES
Question
accordingly negatived.
Amendment proposed: No.
4, in clause 2, page 2, line 22, leave out
‘direct’ and insert
‘advise’.—[Mr.
O'Brien.]
The
Committee divided: Ayes 7, Noes
10.
Division
No.
2
]
AYESNOES
Question
accordingly negatived.
11.15
am
We move
amendment No. 6, given that amendment No. 5 depended upon amendment No.
4 being carried, and I do not want to press that further. In clause
2(5), amendment No. 6 seeks to divest the CQC of its function of
economic regulation. It may help the Committee if I draw attention to
the fact that the amendments to clause 50 would relocate that role to
Monitor, an existing body that already has the necessary expertise and
practice. Those who remember the programming sub-committee will recall
that we had hoped that Monitor would be able to give evidence during
the oral evidence sessions. The Government chose not to take up that
suggestion, but here is where it would have been relevant for our
considerations.
Economic regulation covers all
aspects of the operation of the social market. An economic regulator
needs to possess substantial powers to intervene in order to determine
service reconfiguration and the management of NHS trusts and to decide
how service requirements must be met. A quality inspector needs to
report openly and frankly on the quality of services provided. There is
a tension between the two: the need to drive efficiency from an
economic point of view may conflict with the need to warn about the
potential of declining standards of care from a quality perspective.
Oddly enough, the example that my hon. Friend the Member for Tiverton
and Honiton gave in the last group would be a good example to bear in
mind as we look at that tension.
For example, the economic
regulator may sanction the rationalisation of a trust’s estate
from two sites to one. That is something we can all imagine, as we
often face testing decisions in our constituencies. However, that may
be detrimental from a quality perspective. If the two regulatory
functions are combined, there is a risk that one side of the argument
will be lost, and such conflicts of interest will make a regulatory
regime, in which economic regulation and quality inspection are
combined, unsustainable. The amendment gives rise to the opportunity
for those two functions to remain separate, as indeed they are, with
Monitor, highly qualified and well experienced, taking the role of
economic regulation, and the CQC functioning as a quality and value for
money inspectorate.
Mr.
Bradshaw:
As the hon. Gentleman acknowledges, the
amendment originates in his party’s desire massively to extend
the powers of Monitor beyond its current role as champion and partial
regulator of foundation trusts to being the economic regulator for the
whole health and social care system. It is rather like his idea of an
independent quango to run the NHS and we think that there are
fundamental flaws in that idea because of the potential massive
conflict of
interest.
The
amendment suggests that the new commission has or should have no
interest in trying to ensure that care services are delivered
efficiently and effectively, which is a surprising position for the
Conservatives to take. We believe that quality of provision is
maximised when services are provided efficiently and effectively. The
annual health check of hospital performance published by the
Healthcare Commission shows a strong correlation between high
performance on the quality of care and high performance on financial
management. We think that it is important for the new independent
commission to carry over the responsibilities that the Healthcare
Commission and CSCI currently have to ensure effective and efficient
delivery of services.
Kelvin
Hopkins:
I want to make the simple point that if resources
are used more efficiently, that will provide resources for putting on a
better service rather than simply saving public
money.
Mr.
Bradshaw:
My hon. Friend is absolutely right. There is a
strong correlation between hospitals that are well managed financially
and a high quality of service. Clearly, if a hospital is badly managed
financially and lurching from one financial crisis to another with
a
boom-and-bust approach, patients suffer. That is why
it is important that the new independent CQC retains responsibility and
why we are not in favour of the massive expansion of the empire of
Monitor.
Angela
Browning:
It is a pleasure to serve under your
chairmanship, Mr. Conway. We have something in
common—the occasional senior
moment.
The
Minister’s remarks focused on the NHS, but social and,
particularly, residential care are within the scope of the Bill. I am
concerned about that focus, because a big problem in residential care
is that it is common practice for many people who require residential
care to be placed by social services in homes that are really suitable
only for residential, as opposed to nursing, care. Nursing patients are
often placed in residential care homes purely on the ground of cost.
Many private residential care homes have reluctantly taken such
patients because their arms have been twisted by social services
departments, which then pay a residential rate for what is ostensibly
nursing care. One difficulty, which is being reversed by the closure of
many private homes, has been that residential homes have reluctantly
taken such people purely to fill their beds. The economics are somewhat
questionable for them, and it is surely not acceptable for the
resident. That is a different matter from the Minister’s points
about the
NHS.
Sandra
Gidley (Romsey) (LD): I am listening to the hon. Lady with
interest, because I was fairly persuaded by the Minister’s
points about health. Will she extend her argument to include the
treatment of the elderly mentally infirm, for whom local authorities
struggle to find places in appropriate settings? They are often put in
a home that, although it may be a nursing home, does not have the
expertise and may be
cheaper.
Angela
Browning:
The hon. Lady has touched on a subject dear to
my heart. She mentions the elderly infirm with added mental health
disorders in residential care. With old age comes dementia on a much
wider scale and when somebody’s mental health deteriorates,
particularly in that way, relatives or social services are often asked
to move them to more appropriate settings, of which there are a
shortage. Even worse, it is common practice to medicate those people in
such a way that they become controllable in a different environment,
which is outrageous. The over-prescription of drugs in such situations
needs seriously to be
examined.
Jeremy
Wright:
My hon. Friend will know that the all-party group
on dementia, which I chair, is investigating precisely that subject.
Does she accept that, because of the shortage of places for elderly
people with mental infirmity, some people are in places that are not
technically defined as suitable for the elderly mentally infirm, but
they and their families are happy for them to be there? Their condition
might deteriorate if they were moved into an unfamiliar
environment.
Angela
Browning:
Exactly so, and my hon. Friend’s work
with the all-party group has helped to highlight issues that are hidden
below the surface but extremely important. In responding to the
submission on the clause by my hon. Friend the Member for Eddisbury, I
am making the point to the Minister that the Bill applies to social
care as well as health. I hope he will reflect on that because there
are different issues that come into play and the clause tabled by my
hon. Friend seeks to address the whole Bill, not just part of
it.
Mr.
O'Brien:
I am tempted to find a way of helping the
Minister intervene so he can confirm the point just made and say
whether he also agrees that the Bill extends fully to social care
settings and health care settings.
Mr.
Bradshaw:
I am happy to answer that. I thought that I had
made it clear in my remarks that the existing legislative framework
will do exactly the same. There is a duty on the CSCI, as there is on
the Healthcare Commission, to be concerned with economy and efficiency.
That is exactly what we are taking forward in the
legislation.
Mr.
O'Brien:
I am grateful to the Minister for confirming
that. At the heart of the matter is the importance of recognising that
although the Healthcare Commission covers both aspects of regulation,
Monitor covers only economic aspects. When moving forward, it will be
absolutely vital that we have an understanding of the different
pressures and potential conflicts of interests that may arise. We have
introduced a proposal that we think will work, but given that we will
revert to this matter when we get to clause 50, it would be
disproportionate to press the amendment to a vote at this time. It has
been a useful exploration of the issue and I hope that when we get to
clause 50 sometime soon, we will be able to see whether the Minister
has had a chance to reflect on the matter. I beg to ask leave to
withdraw the
amendment.
Amendment,
by leave,
withdrawn.
‘(6) Where, in the
course of performing its functions, the Commission becomes aware of
substantial risks to the dignity, rights or welfare of any individual
affected by the failure of a service to comply with regulations, the
Commission shall ensure that any necessary action is taken to safeguard
that individual, and to support them in taking action to safeguard
their own dignity, rights and
welfare.’.
The
amendment seeks to strengthen what a number of organisations have
called a rights-based approach to the CQC and its responsiveness to
warning signals. To some degree, the amendment is a more generic way of
looking at a rights-based approach than some of the more specific
amendments that originated in the private Member’s Bill on the
human rights application in certain social care settings. The amendment
is core to that debate. I know that the hon. Member for Luton, North
has dedicated himself to understanding the issues surrounding the
rights-based approach. I hope that the amendment commends itself to him
because it effectively maintains the current powers of CSCI within the
new CQC. That is vital, because on the basis
of how the Bill is currently drafted, there is concern that the powers
enjoyed by CSCI will be diminished on the arrival of the
CQC.
It is likely
that in the course of investigations about non-compliance with
regulations, the regulator will encounter situations in which there are
risks to the rights and welfare of specific individuals. The Bill
should clarify the duties of the regulator to take action to safeguard
and promote the rights and welfare of children and vulnerable adults
under the circumstances that patently fall within the ambit of clause
2(3)(d). Age Concern sets a good example by supporting the amendment
and proposes the addition of a duty to investigate when the commission
suspects an individual is at risk. As I have said, Age Concern supports
the amendment and I pay tribute to its assistance in drafting it. The
recent cases of deaths at Parkfields residential home in Butleigh,
Somerset, is an example of CSCI using the power to investigate. The
couple in that case were accused of murdering five residents and CSCI
used that power, although a bit late. One resident died and CSCI saw
what it thought was a substantial risk and did a snap inspection,
following which it applied for an order and closed the home. The other
people who died did so before that action was
taken.
11.30
am
Ideally, such
a function in the commission would be supported by an effective
complaints procedure and body, which would flag up potential problems
through that process. We will find that there are other opportunities
throughout the Bill to debate that in more depth. Does the Minister
agree that this has been a useful power for CSCI, given what is a
pretty powerful example? Does he expect that power to carry over into
the CQC? We cannot find that in the Bill. I hope that agrees that
subsection (6), by virtue of the amendment, is a helpful and
constructive approach to a problem that he said that the Bill aims to
address.
Greg
Mulholland:
There appears to be a need to clarify the duty
of intervention that the new CQC will have when it suspects that an
individual or individuals are at risk, and the amendment is useful for
that. As we know, and as we have heard in the particularly extreme
recent example at Parkfields, the new commission will inevitably
encounter situations where the welfare or rights of the individuals are
at risk of being infringed by failures in the system. Therefore, it
makes sense for the commission to have a clear duty to intervene. The
point of the amendment is to have that firmly on the face of the Bill.
The Minister’s answer will say whether that is the appropriate
way to do
this.
I am sure that the Minister
will accept not only that we believe that the amendment is useful and
sensible, but that this kind of thing is needed to give a sense of
confidence, in this case, that the new Care Quality Commission is there
to protect vulnerable individuals and to safeguard people, whether in
the health or the social care setting. That is the purpose of the Bill.
My particular concern, and the concern of organisations such as Age
Concern and the CSCI, is that that duty is most needed in the care
sector, particularly when dealing with the most elderly and most
vulnerable
people. It is interesting that the words “dignity, rights and
welfare” have been used. Clearly, this is not just about basic
rights and the duty to intervene for specific health care and
safety-associated risks; there are also risks to people’s
dignity, which it is essential to include in the Bill. The question is
whether the Minister can convince us on whether that should be on the
face of the Bill, or whether it is already there in essence. It is
certainly something that must be specified and I look forward to
hearing what the Minister has to say.
Kelvin
Hopkins:
The hon. Member for Eddisbury was kind enough to
mention my interest in the Human Rights Act, which relates to
amendments that I shall move later. It strikes me that the amendment is
a softer version of my amendment and does not make specific reference
to the Human Rights Act in its application to private care homes. If,
for example, it said “Human Rights Act” in place of
“regulations”, it would be the amendment that one would
like to see. At some point during the progress of the Bill, one would
hope for some guarantee that the rights of people in care will be
protected in that way and that the Government are committed to them. I
will be working hard, from my position, to try to secure that end. I
wonder whether the amendment is a weaker version of my later amendment
or a necessary addition to it. I would be interested to hear the
response of the hon. Member for
Eddisbury.
Mr.
Bradshaw:
Clause 2 already makes it clear that the new
commission must, in everything that it does, pay particular heed to the
need to safeguard the rights and welfare of vulnerable people. Those
priorities will be at the heart of the new organisation in deciding
when and where it needs to act to help to assure the safety and quality
of health and adult social care services. The Bill enables the
commission to take action in response to breaches of any registration
requirements, or breaches of requirements under any other legislation,
including human rights legislation, that it thinks is relevant.
However, we would argue that it should not be the role of the new
commission to provide advocacy in individual cases, as is suggested by
the amendment. We believe that it should be the responsibility of the
commission to ensure that registered providers fulfil their
responsibilities. Advocacy and safeguarding should primarily be the
responsibility of other organisations. It should be the
providers’ responsibility to deliver safe, quality care and the
commission will take action, and if necessary close services, if they
do not.
As we have
discussed before, we have recently consulted on handling complaints and
we proposed that commissioners—both PCTs and local
authorities—should have a more vital role in ensuring that the
processes work effectively. Where those responsibilities are not being
met, the Bill gives the commission tough enforcement powers to follow
up breaches of requirements and, when doing so, to inform other
relevant appropriate organisations that have responsibility in these
areas: for example, commissioners and in extreme circumstances the
police. For example, where the commission identifies unacceptable
treatment of a service user’s dignity by a provider, it may take
action against the provider and
may also inform the local authority, under clause 35, so that it can
follow up issues
accordingly.
Boards
and/or senior managers of provider and commissioning organisations must
themselves be held responsible for ensuring that the care they provide
is safe. Registration requirements, which we will be consulting on
during the passage of the Bill, will require those providing care to
demonstrate that they secure the dignity, rights and welfare of those
who use their services. Although I understand the reasons behind the
amendment, we have already given the commission the powers it needs to
tackle such breaches. The practical effect of the amendment would be to
shift the onus of responsibility from providers and commissioners to
the new commission and risks absolving them and overburdening the new
commission. Therefore we cannot accept the
amendment.
Mr.
O'Brien:
I am rather interested in the angle that the
Minister has taken, because although he has decided that he does not
want to accept the amendment, which I think he detects has a bit of
broad support, he declared himself not wholly unsympathetic to the
sentiment behind it, although he may think that it does not need the
advocacy
aspect.
Where is the
underpinning of advocacy? We have touched on that in our discussion
about independence. All Committee members remember that well in respect
of the community health councils. I am sorry to pray that example in
aid, but those bodies seem to provide a sensible parallel. There is an
absence; the Bill simply relies on the voluntary sector to be
advocates. I ask the Minister to reflect on that.
A coroner, for example, while
obviously dealing with different circumstances, is looking into the
cause of death in a lot of individual cases, but if he or she comes
across aspects of the particular that need to be made available in the
public arena for general understanding, not only does he or she have an
absolute duty and right to do so, but that is strongly welcomed. The
advocacy that is obtained by that process is a task that that
independent body has been charged to undertake. Sometimes, it can make
uncomfortable reading for all of us when the mirror is held up to us as
a legislature and an
Administration.
The
hon. Member for Luton, North deftly described the amendment as possibly
a softened version of something that was coming later. He was right to
observe that it is a complementary and therefore necessary part of
those two things, but I have no doubt that we will have opportunities
to raise issues about the incorporation of a rights-based approach or
even, to use his argument, the terms of the Human Rights Act
1998, later in our considerations. I did not draft the amendment in
relation to the 1998 Act particularly because doing so would have
caused certain consequential drafting issues, with which I am sure he
is familiar. The amendment is a more effective way of trying to achieve
some of the main, underlying principles that he is also trying to
secure, with every sympathy. This matter has also exercised those
representing the Liberal
Democrats.
We will be
able to return to the issue again. I am more hopeful than I might have
been—I hope it is not hope over expectation—that the
Minister will take time to reflect on this set of arguments. It would,
of course,
be quite wonderful if he intervened, or if he were
to indicate that he will think about it and possibly bring back on
Report something that would reflect what is becoming a bit more of a
cross-party
approach.
Sandra
Gidley:
Does the hon. Gentleman agree that in some ways,
the amendment is about raising the bar? I was slightly alarmed when the
Minister said that in serious breaches, the police will be called in.
When it comes to the concept of dignity, there are many examples that
are not criminal, would not seem serious enough to warrant that sort of
involvement and may be deemed less important. His amendment is useful
because, if it is accepted, the Bill will stress that that is something
that the commission should have regard to. I do not think that the
current wording is as strong as the wording that the hon. Gentleman has
suggested.
Mr.
O'Brien:
I am grateful to the hon. Lady for that approach.
Perhaps it will help to reinforce the point that she has helpfully made
if I tell her about what I had in mind when I was looking at the
amendment. It goes back decades now, but I was terribly struck by it,
and have carried it around in my head—to be personal for a
second, if the Committee will indulge me.
My mother
was a nurse for many years, and I recall her saying about the issue of
dignity, before it became a more commonly used, fashionable word, that
the absolute quality of care was tested when, if a patient going to or
coming back from theatre, is anaesthetised—this applied to both
sexes, but she said it in relation to women in particular—the
bed clothes on the trolley were not properly arranged and the patient
was not properly covered. Even when they had no control over that, and
may never have known that their personal dignity had been assaulted, it
was the absolute test of professional care that a nurse would
immediately go and arrange those blankets so that the personal dignity
of that individual was maintained.
That is highly relevant to
what I am trying to suggest here as a rights-based approach. The right
to dignity is absolutely in the mind, even if it is not of the criminal
variety, which would be of a different order of magnitude. I hope that
that type of example underpins the genuine sense of professionalism and
deep care that is recognised by all members of the Committee, and which
we want to imbue as the standard against which everybody will be judged
in all health and social care settings.
Kelvin
Hopkins:
I appreciate entirely that the natural human
response is to accord other people dignity, and one would hope that
that would always be the case. However, a culture is frequently
established by law. Throughout history, particularly the last couple of
hundred years, we have had to change the law time and again to ensure
that people are treated properly. I have no doubt that the hon.
Gentleman’s mother, and many others in my family who have worked
in care circumstances, would behave well, but there are some who will
not. To ensure that that culture exists and is universal, I think that
the force of law is necessary.
Mr.
O'Brien:
I am grateful to the hon. Gentleman. Many other
amendments reflect and bear upon people’s rights, I think that
this area is patently absent from the Bill. It is within our capacity
as a Committee
to sort it out and correct it. I very much hope that this amendment, or
one brought back in a different form by the Minister, having reflected
on the discussion, on Report, will deal with the issue. That will be an
ideal opportunity to do so. Failing that, I dare say that it will be
picked up in another place in a more determined manner. I would
encourage those in another place to do so, not least after reading what
I have just said. I hope that we can readdress that matter.
We are not seeking to cast
aspersions, or to assume that people, particularly those dedicated to
care services, are not naturally focused on the dignity and the rights
of the individual. However, as the hon. Member for Luton, North rightly
said, so often, it is the statutory expectation, underpinned by the
law, that means thankfully that the law has rarely to be used. It is
setting a benchmark of behaviour and expectation that gives people the
knowledge that they are doing the right thing. Having reflected on what
the Minister has said and, with a glimmer of hope that he will think
about the matter on Report, I beg to ask leave to withdraw the
amendment.
Amendment,
by leave,
withdrawn.
11.45
am
Question
proposed, That the clause stand part of the
Bill.
‘(1)
Notwithstanding the provisions of section 2(4), the principal duty of
the Commission in carrying out its functions shall be to protect and
further the interests of patients, service users and the public in
relation to the quality and safety of care
services.
(2) In carrying out
its duty under subsection (1) the Commission shall
encourage:
(a) the continual
improvement of the quality of the activities to which its functions
relate,
(b) the carrying out of
such activities in a way that focuses on the needs and experience of
those for whose benefit the activities are carried
on,
(c) the involvement of
patients and service users in the work of the Commission wherever the
Commission considers this appropriate including, in particular, in the
processes of review and inspection,
and
(d) the efficient use of
resources in the carrying out of the activities to which its functions
relate.’.
Mr.
O'Brien:
New clause 1 sets out the duties of the Care
Quality Commission to encourage continual quality improvement, service
user and patient-focused care, the involvement of patients and service
users in the CQC’s work and the efficient use of resources. I am
sure that other members of the Committee will have been approached by
the Picker Institute, which has sought the new clause, and we were
happy to table it to ensure that the issues are properly considered and
addressed. It improves and adds to the current description of the
commission’s functions—part of an earlier
debate—and the things to which it must have regard. It replaces
clause 2(5) and goes beyond the emphasis in clause 2(3)(a) and (b) on
the views and satisfaction of the public, by adding a focus on the
experience and engagement of patients and service users. New clause
1(2)(a) and (d) raise the existing wording in clause 2(5) to the level
of general duties.
New clause 1(2)(a) and (b)
give the commission a strengthened mandate to promote continual quality
improvement—something I thought we would all agree with entirely
and want to see supported. The provisions will help to ensure that the
regulator’s efforts and resources are not overwhelmingly focused
on risk-based detection and the elimination of the poorest performing
service providers, but also make a due contribution to the general
improvement of services over time.
New clause 1(2)(b)
additionally requires the commission to encourage service providers to
focus not only on meeting the needs of service users, but also on their
experience of using the services. Evidence shows that raising the
quality of the service user’s experience contributes to
increasing the effectiveness and improving the outcomes of care as well
as user or patient satisfaction. That was based upon patient-focused
interventions and a review of evidence by A. Coulter and J. Ellins of
the Picker Institute for the Health Foundation in 2006.
New clause
1(2)(c) likewise reflects evidence that the involvement of patients
increases the effectiveness of care and improves its outcomes. It
reflects best practice in the regulation of health and social care
services and the production of patient and user centred care. It will
act as a general mandate to pursue that goal through various aspects of
the work of the regulator, including developing guidance on complying
with registration requirements, developing methodologies of performance
measurement and review and improving the effectiveness of review and
inspection activities. Without such a duty the models of user
involvement developed by existing regulators may be lost in the
transition, especially because budgets will be lower and if the board
of the new commission is not drawn from among the existing
regulators.
The
Government have
stated:
“The
Care Quality Commission’s...priority will be to safeguard
service users and help improve their experience of health and adult
social care services - recognising that it can only do this effectively
by involving them. It will be able to build on good work done by the
Commission for Social Care Inspection, the Healthcare Commission and
the Mental Health Act Commission, which all emphasise the importance of
involving service users, and their carers, in their
work”.
I hope
that the Minister will be willing to amend clause 2 accordingly, which
will be useful, I presume, in establishing the rights and duties that
we are debating. There are a number of issues that we could read in
from other debates on other clauses, but it is clear that, without
wanting to take up the Committee’s time unduly, it is sensible
to recognise that the proposal sits well with, and is consistent with,
a raft of the amendments that we have already considered. I am sure
that that consistency will be welcomed.
Greg
Mulholland:
Our debate on clause 2 has been useful, and
although the Minister has not accepted any of the amendments, he will
accept that there are concerns about the fact that the CQC’s
duties are not laid out as fully as certain organisations would
like.
Much of new
clause 1 would help to clarify the point that the new commission should
put the needs of patients and service users first, but the crucial
provision, which we support, is subsection (2)(c). Currently, the
commission will only “have regard to” the views of
members of the public, but that phrase is almost meaningless. From my
own rows with NHS trusts, I know that it is exactly the kind of phrase
they can hide behind, claiming that they have “had
regard” to all sorts of views expressed by the public. All too
often, that becomes an excuse for not informing the public, never mind
holding meaningful consultation with patient groups—there is not
too much of that in the NHS nowadays.
It is therefore useful and
important—indeed, fundamental—to the whole essence of the
new CQC that we use the phrase
“involvement of patients and
service users”,
rather
than referring just to the general public. Empowering the patient is
something the NHS does not do enough, and we have an opportunity to
address that today. The Commission for Social Care Inspection has
called patients and service users “experts by
experience”, but we do not seem interested in hearing the views
of those experts.
Patients and service users
absolutely should have a defined and genuine role in the new system of
inspection and regulation, and it is entirely sensible to make that
clear in the Bill. Subsection (2)(c) of the new clause gives us the
opportunity to do that, and including it in the Bill would send the
clear message that we want patients and service users to be involved
and that we see them as stakeholders in the health service and the care
sector. They are not sufficiently involved at present, but the
unamended Bill does not address that, so it represents a huge missed
opportunity.
I look
forward to hearing what the Minister has to say. We strongly support
subsection (2)(c). We support new clause 1 in essence, but subsection
(2)(c) is crucial if we are to achieve the kind of regulatory system
that patients and service users deserve.
Angela
Browning:
I would like to speak to new clause 1 because it
is important that the Bill sets out the commission’s duties in
the same format as the new clause. The interpretation of the
commission’s duties should not be left to guidelines or
secondary legislation. It is important that the changes with which I
think the Minister is presenting us are set out in the Bill, because
they will vastly strengthen and improve outcomes for patients and
service users.
I
support the idea that, as I understand it, the Bill is not just about
having an inspectorate that is like a police force, which goes around
checking when things are wrong and filling in check-lists—in
other words, giving an historical account of what has happened. Of
course, if we are to protect patients and service users, it is
important that inspections are carried out regularly and have teeth
when they find that things are wrong. In tandem with that, however, it
is important that we drive up standards, which must be for the benefit
of service users. Service users and patients should feel confident not
only that there is a combined inspectorate, but that standards and
quality are improving as a result of its activities. It is important
that that is made clear in the Bill.
There is a second aspect to new
clause 1 that has not yet been mentioned. Many of us have dealt with
members of staff working in both health and social care who themselves
have almost become victims of the failure to drive up standards.
Professional staff will appreciate the fact that the Bill defines the
real focus of the commission, because that benefits not just patients
and service users but those involved in social care and the NHS. That
is very important. In an inspectorate, there is always a danger that
people will think in silos; in other words, what is required of them is
sometimes seen as divorced from some of the issues that we have
mentioned in Committee, such as quality of life and protection for
patients and service users. Clearly defining the duties of the
commission will enhance what the Minister seeks to do in bringing
together the inspectorates, so that the CQC is not just a police force
but drives up the quality of care for service
users.
Mr.
Bradshaw:
Eagle-eyed members of the Committee will
recognise the new clause as a bundling together of several of the
amendments that we discussed at some length on Tuesday. I will not
repeat everything that I said then except to say in summary that we
believe that the essence and desires behind the new clause are already
in the Bill, in particular the issue that has just been raised. I
entirely agree with the hon. Member for Tiverton and Honiton about the
need for one of the functions of the new commission to be continual
improvement, which is clearly stated in subsection (5)(a). We debated
that point at some length on Tuesday. Paragraph (d) of the new clause
proposed by the hon. Member for Eddisbury would reintroduce the
efficient use of resources, which his amendment sought to delete. I do
not quite understand that. Perhaps it is just an innocent mistake. I
think that the new clause is flawed and
unnecessary.
Mr.
O'Brien:
In suggesting that we are re-debating something
that we have already debated, the Minister does not quite understand
the full import of what has been drafted. In the context of the
somewhat unsatisfactory response from the Minister and the fact that
this is a clause stand part debate, it is important to flag up the fact
that as far as clause 2 is concerned, we have received no guarantees
that the good work of the former regulators will be carried over in its
entirety. We have had no guarantees of a general function for the
commission. In the oral evidence, it was recorded that although leaving
everything to regulation is the ultimate flexibility it is also the
ultimate straitjacket because it depends on how the Secretary of State
frames the legislation. We have had no guarantees of proper service
user involvement and a national patient voice through Local Involvement
Networks.
We
continue to have concerns about the Care Quality Commission’s
lack of focus on all, rather than just vulnerable adults, particularly
carers—a point that was strongly reinforced by my hon. Friend
the Member for Tiverton and Honiton. We have no guarantees of proper
independence in clause 2(4) and we have had no separation of economic
regulation from quality and value-for-money regulation. If we cannot
have that, we cannot have new clause 1 either.
It is deeply disappointing
that we have not managed to persuade the Minister. I had some hopes
that we might. While it would not be appropriate to
seek to
divide the Committee on clause stand part, I want to register our
intention to divide the Committee once we reach the appropriate moment
on new clause
1.
Question put
and agreed
to.
Clause 2
ordered to stand part of the
Bill.
Clause 3
ordered to stand part of the
Bill.
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