Clause
42
Periodic
reviews
Mr.
O'Brien:
I beg to move amendment No. 30, in
clause 42, page 20, line 27, after
first ‘of’ insert ‘the quality
of’.
The
Chairman:
With this it will be convenient to discuss
amendment No. 31, in
clause 42, page 20, line 32, after
first ‘of’ insert ‘the quality
of’.
Mr.
O'Brien:
The amendments seek once again to limit the scope
of the commission to reviews of quality and value for money, rather
than economic viability. The debate will be akin to some degree to that
on amendment No. 6 to clause 2, at column 175 of the Official
Report. I am sure that members of the Committee will recall that I
talked about economic
regulation covering all aspects of the operation of the social market.
The economic regulator would need to possess substantial powers to
intervene in order to determine service reconfiguration and the
management of NHS trusts, and to determine how service requirements
must be met.
However,
a quality inspectorate needs to report openly and frankly on the
quality of the services provided. There could be tension between the
two activities. We hope not, but I dare say that we can all envisage
circumstances where the need to drive efficiency from an economic point
of view might conflict with the need to warn about the potential of
declining standards of care from a quality
perspective.
When we
discussed the matter before, I must say in fairness to myself that the
Minister misrepresented the position. I am putting forward the
desire—a party position—not to extend massively the
powers of Monitor, which suggests a net increase in regulation, but to
transfer the economic regulation role of the CQC to Monitor. As the
Minister knows, we were unable to take oral evidence from Monitor. We
had hoped to do so, but that was not possible due to compromises made
on the programming.
In
the foundation trust sector, which is relevant to the work of Monitor,
quality and economic regulation are already divided along those lines
and to those bodies. Our position aligns with our desire to see all
trusts achieve foundation status. I should be interested to hear the
Minister’s explanation of his contention that our establishment
of an NHS board poses a potential massive conflict of interest. That
would happen only if politicians continue to want to run the NHS,
rather than to provide the means by which it can be run with clinical
priorities as the first order of concern. I hope that the Minister has
had time to reflect on matters and sees the merit in our
proposals.
Mr.
Bradshaw:
The hon. Gentleman said that he wanted to retain
the role for the review of value-for-money elements, but that would be
excluded under the amendment. It would restrict the scope of Care
Quality Commission reviews simply to the quality of provision. I
understand his desire to extend the remit of Monitor, but I would not
be in favour of restricting the reviews of the commission in that way,
and nor would the commission, I believe, given what we heard during our
evidence session.
Of
course, the reviews will look at the quality of provision. Subsection
(4) sets out that assessments will be conducted
by
“reference to such
indicators of
quality”
set out by the
Secretary of State, or delegated to the commission to determine. The
reviews will need to look at more than the quality of services. For
example, when assessing local services we want greater emphasis to be
put on how well they are working together to achieve overall outcomes,
and to see whether they reflect the needs of their local populations.
We will talk later about commissioning, but the reviews may consider
the commissioning record of a primary care trust and how well it is
meeting the needs of local people. Those issues seem to go beyond the
strict definition of quality in the amendment, which is the main reason
why we wish to resist it. We will discuss the role of Monitor at
greater
length later, but I point out to the hon. Gentleman that Monitor covers
only foundation trusts, not all registered providers, and this is not
just about NHS
care.
Mr.
O'Brien:
We will not press the amendment to a vote because
I can see that we will not win on this one, and I will withdraw it on
that basis. However, I hope that the Minister will take the following
point seriously. If one genuinely hopes, as I believe his Department
does, that all trusts can move toward foundation trust
status—that is our stated aim, and by the very nature of what is
intended, that must be the aspiration—it would make more sense
if the regime that covers FTs, in the light of how Monitor divides up
its responsibilities, is consistent with the provision that we are
considering. That said, I beg to ask leave to withdraw the
amendment.
Amendment,
by leave,
withdrawn.
Sandra
Gidley:
I beg to move amendment No. 195, in
clause 42, page 20, line 28, at
end insert—
‘(aa) conduct
reviews of the making of arrangements for the provision of healthcare
by the
Trust’.
The
Chairman:
With this it will be convenient to discuss the
following amendments:
No. 261, in clause 42
, page 20, line 28, at end
insert—
‘(aa) conduct
reviews of arrangements made under paragraph (a)
above’.
No.
263, in clause 44
, page 21, line 39, at end
insert—
‘(d) the making of
arrangements by a Primary Care Trust for the provision of health
care.’.
Sandra
Gidley:
The amendment is a simple one and was tabled after
listening to the oral evidence. I was struck by the powerful arguments
made by Anna Walker when she was asked what the powers of the new Care
Quality Commission should be. She expressed concern that the Bill, as
drafted, focuses too much on the regulation of providers, whereas the
provision of health care is about what care is purchased or
commissioned on behalf of the user, as well as the provider. I do not
usually read out large quotes, but it is worth reminding the Committee
of what she went on to
say:
“that is of course
also true for social care. We have concerns about two particular areas.
The Bill, as drafted, gives the new regulator the power to carry out
wider reviews. That is welcome, because it is under that power that we
have looked at learning disabilities, mental health and dignity in care
for older people in hospital, so it is a very important power to us.
The difficulty is that it is limited to providers only. What we find in
health care—I must leave it to others to talk about social
care—is that you can say to a provider, ‘Look, that
service simply isn’t good enough’, to which their answer
can often be, ‘But we are not being paid to provide any more
than that.’
In
order to get the issue right, on behalf of the user and the patient,
you have to look at a mixture of commissioning and provision; what the
primary care trusts are doing, as well as what the provider is doing.
We would like to see that power for the wider review cover
commissioning as well as provision.”—[Official Report,
health and social care Public Bill Committee, 8 January
2008; c. 17, Q25.]
That is a
laudable principle.
I do not want to pre-empt the
Minister’s comments, but I fully accept that practice-based
commissioning is fairly new. It does not work terribly well in some
parts of the country and I am told that is being replaced by something
called world-class commissioning, for which we wait with bated breath.
There are problems with some of the probity of commissioning.
Sometimes, the commissioners are in effect consulting GPs who
commission services from themselves—there are not enough Chinese
walls in place.
The
amendment tries to pull back the focus, so that it is not simply some
cosy little group deciding what services are commissioned from where. I
am not saying that all groups are like that, but I dare say that the
odd one is. The amendment would provide an extra provision, so that the
commission could come in and say, “You are doing it wrong. You
are not providing service of the best quality and the problem has
arisen because of the
commissioning”.
The
amendment may not be perfectly drafted, but the general principle is
important. I hope that the Minister can reassure me that he is at least
rethinking the
matter.
1.45
pm
Mr.
O'Brien:
We have tabled amendments Nos. 261 and 263. The
hon. Lady was honest enough to say that perhaps her amendment is not
perfect in all respects. Amendment No. 261 provides an alternative
opportunity, as it seems to achieve much the same thing. Amendment No.
263 would enable special reviews of commissioning practice, for
example.
What is
important here is the point that Anna Walker made to the hon. Member
for Leeds, North-West during the oral evidence: in order to get the
issue right, the mixture of commissioning and provision has to be
looked at, as does what the PCTs and the providers are doing. That
power for the wider review should cover commissioning as well as
provision. The Committee might also want to read “local
authorities” with “PCTs” and even go as far as
including “individual private purchasers of social care”.
If we end up finding that, unusually, the Minister is not able to
accept our amendments perhaps he would like to add that to his
“Reflect” box for what I hope will be a monumental
improvement by the time we reach Report.
I will give an example. The
Healthcare Commission’s annual health check for 2008-09 will
assess PCTs on the quality of their commissioning. We need to ask
seriously whether that will continue under the new CQC. I also alert
the Committee to a report on 2 August last year in the Financial
Times, which stated
that
“a battle had broken
out”
between David
Nicholson, the NHS chief executive, who sees the PCTs as part of his
management empire, and Anna Walker, who said that there must
be
“a mechanism for
holding people publicly
accountable”
for the
quality of purchasing. The report went as far as to say that one
Department of Health official shared that view while others opposed it.
I shall not endeavour
to catch the eye of any of the cast of officials that the Minister has
with him today. Under Anna Walker’s system, it would remain the
job of the strategic health authorities to performance manage the
primary care trusts, but there is a need for an independent assessment
of their performance. The NHS Confederation has also
backed the idea of independent assessment, saying that it was
needed
“for reasons of
public
accountability”.
The
point is a strong one, it commends itself and I hope that the Minister
feels persuaded.
Mr.
Bradshaw:
I am grateful for the opportunity to discuss
this issue, not least to put on the record that we are completely
committed. The hon. Member for Romsey asked me to rethink, but I do not
think I need to—I am in the same place as she is and I agreed
with everything that she said. We are completely committed to the
independent performance assessment of PCT commissioning and we believe
that that should be a role for the Care Quality Commission. That is
provided for in the Bill, and I will explain why in a minute. It is
entirely right for that to be the case given that 80 per cent. of
taxpayers’ money is now spent on the health service through
primary care trusts, which are the main commissioners.
There was widespread support
for that during our consultation on the proposals in the Bill. That is
why clause 42 requires the Care Quality Commission to review PCT
commissioning, as well as the health care that they provide. Subsection
(1) requires the commission to conduct overall reviews of the health
provided in each PCT area, whether provided by the PCT itself or by
other people under arrangements made by the PCT. Those reviews will
assess how well PCTs are meeting the needs of their local populations.
PCT provision will also be reviewed in its own right under subsection
(2).
Clause 44 covers
commissioning by local authorities and primary care trusts, and how
that impacts on the services people receive and the health of the local
population. The commission is able to investigate specific incidents,
or series of incidents that put the health, safety or welfare of people
at risk. That would include looking into the decisions that have led to
that situation arising, such as the commissioning.
Given that reassurance, and the
positive discussions that I have had with Anna Walker about the issue
over many months, I hope that the hon. Lady will be reassured enough to
withdraw her amendment.
Sandra
Gidley:
I am not entirely convinced that Anna Walker was
reassured, judging by her comments during the evidence-taking session.
I fully accept that clause 44 allows for special reviews and
investigations and I can see that that is covered. However, it would be
useful to amend the wording to clarify that that is a key part of the
role. At this moment it is best to reflect on the Minister’s
comments and perhaps go back to the Healthcare Commission to see
whether it is as reassured as he claims. I beg to ask leave to withdraw
the
amendment.
Amendment,
by leave, withdrawn.
Mr.
O'Brien:
I beg to move amendment No. 135, in
clause 42, page 20, line 30, at
end insert—
‘(d) in
conducting reviews under subsection 1(a) the Commission shall review
and assess annually the Trust’s plan for improving health, as
prepared under section 24 of the National Health Service Act 2006 (c.
41).’.
The
Chairman:
With this it will be convenient to discuss
amendment
No. 136, in
clause 42, page 20, line 40, at
end insert—
‘(d) in
conducting reviews under subsection 3(a) the Commission shall review
and assess annually the plan for improving health insofar as it impacts
upon the authority, in accordance with section 24(3) of the National
Health Service Act
2006.’.
Mr.
O'Brien:
Let us see whether we can get this amendment away
from the “Reflect” box. The amendments would give the CQC
the power to inspect PCTs’ plans for improving health, with the
intended consequence that they would take such plans seriously. It is
not a draconian or over-prescriptive measure, but I suspect that the
power to inspect is in itself a potentially powerful tool. PCTs already
have powers to publish an annual health improvement and modernisation
plan—HIMP. Those were originally under section 28 of the Health
Act 1999 and are now under section 24 of the National Health Service
Act 2006, which sets the framework for the local commissioning and
contracting of services.
I have already outlined what we
have argued are the significant failings of the Government on public
health. The force of these plans, therefore, will be to seek to combat
widening health inequalities and poor public health at a local level. I
will not repeat the arguments that we had in relation to other clauses,
but that is what lies behind our concern and why this would be a
pragmatic, cost-efficient measure to include. I hope that the
Government find that it commends itself, because we would require all
PCTs to produce such plans and require each PCT’s coterminous
local authority to be consulted on their development. Of course,
overlapping authorities would therefore have to be on a
multi-consultation process.
In those cases where agreement
between local authorities and PCTs cannot be reached, disputes would be
resolved in the first instance by the relevant strategic health
authority, with a right of appeal to the NHS board. If the HIMP
involves a major service reconfiguration, the independent
reconfiguration panel would be consulted as necessary. I want to ensure
that the Minister realises that this is a genuinely thought-through,
sensible proposal that is not particularly sizeable but is significant.
I genuinely hope that he will find himself persuaded by the
arguments.
Mr.
Bradshaw:
As we have already emphasised, the
commission’s reviews will cover the whole range of functions
carried out by bodies in relation to health care and adult social care,
including public health and community services. Where we differ from
the hon. Gentleman is that while we believe that the local plans will
look at what PCTs and local authorities plan to do, the role of the
commission will be to focus on the outcomes for the people who use
those services. He referred, rightly, to the differentiation between
the role
of performance management by the strategic health authorities, and
regulating. I suggest that the amendment, which would require the
commission to review the plans, strays a little further on to the
performance management role than we think is a good idea. I am afraid
to disappoint him, but I will resist the amendment.
Mr.
O'Brien:
I am not sure that I can take much more
rejection. I am tempted to dwell on the point, which is probably my
best lever. If I cannot persuade the Minister, I cannot. He spoke about
reviewing and having too much of a hands-on approach, but this power
was drafted as “inspect”. I accept that if someone
inspects they are likely to have a view as to whether that amounts to a
review, but I do not want to split hairs on that. However, the power of
inspection was more to have something that would urge people to ensure
that they got it done in a timely fashion.
I was initially sceptical when
the Government suggested—it is a direct parallel and involved an
area like mine, which I suspect is not dissimilar to parts of
the Minister’s constituency—that it would be appropriate
for parishes to bring in parish plans. I saw that as yet another piece
of written bureaucracy that is going to tie people up. Instead, it has
served to bring focus and energy into local communities to decide what
they want collectively to make their priorities. In many
cases—not all—it has served to be a good, rather than a
burden. I wanted to inform what is going on here through that process.
The fact that one has the right to come in and inspect, whether or not
an inspection has been made, encourages that to happen without being
over-prescriptive.
As
I say, I do not think that I have been able to persuade the Minister,
but I hope that, as a final flourish, he might put that also into the
“Reflect” box. I beg to ask leave to withdraw the
amendment.
Amendment,
by leave,
withdrawn.
Sandra
Gidley:
I beg to move amendment No. 137, in
clause 42, page 21, line 1, leave
out subsections (4) to (8) and
insert—
‘( ) The Secretary
of State shall not create any indicators of quality additional to those
in the National Indicator
Set.’.
The
Chairman:
With this it will be convenient to discuss the
following amendments:
No. 93, in
clause 42, page 21, line 11, at
end insert—
‘(7A) In setting
out the indicators under subsection (4) for assessing each English
local authority, the Secretary of State
shall—
(a) have regard
to the National Indicator set,
and
(b) in such cases as the
indicators impose a regulatory burden on local authorities beyond the
National Indicator Set, lay draft regulations before
Parliament.’.
No.
32, in
clause 42, page 21, line 16, at
end insert—
‘(c) all
relevant statements submitted to the Secretary of
State.’.
Sandra
Gidley:
This is a probing amendment. I think that the
Minister is going to disagree with me, but significant concerns have
been expressed by some of the existing regulators, who see increased
powers for the Secretary of State, and less flexibility for the new
commission.
The amendment attempts to take
out some of the indicators that the Secretary of State may approve, or
that the commission may submit to the Secretary of State for approval.
By sticking to the national indicator set, that would also potentially
give the new commission some protection from a future Secretary of
State for Health displaying megalomaniac tendencies, and wanting to
impose something on the
commission.
As I say,
this is a probing amendment, and it seeks some clarification on what
autonomy the commission has to review something that it deems
important, and how much interference it could potentially be subjected
to under the clause as currently drafted.
Mr.
O'Brien:
I note that the amendment seeks to deal with
megalomaniac tendencies, which struck me, coming from the Liberal
Democrats, as a little “Dream on”. That was meant to be
friendly and light-hearted.
Sandra
Gidley:
I am
wounded.
Mr.
O'Brien:
Not half as wounded as I am, given the rejection
that I have been receiving from the other
party.
2
pm
Amendments
Nos. 93 and 32 are slightly more toned-down versions of the Liberal
Democrat amendment. It appears that the Local Government Association
has sought to brief both the official Opposition and the Liberal
Democrats. We want to ensure that the amendments, which have arisen
from the LGA, deal with the regulatory burden on local authorities and
whether that would be disproportionate, given the various angles from
which they are regulated. As an example of the stringent approach that
we have taken to our amendments, we returned some of those that were
proposed because we felt that they were constraining the CQC in a
blanket way, which could be potentially obtuse. However, on the
amendments that we have been urged to consider tabling through the
various representations made to us, we have said that the CQC should
have a statutory responsibility to have regard to the national
indicator set when setting its regulations, and that Parliament should
have the power to monitor the regulations if they become
over-burdensome.
My
record in the House as being completely, utterly and unashamedly
opposed to over-burdensome regulation—not least when I had a
different portfolio in the shadow team—will commend the fact
that the amendment has been not only put forward with some genuine
concern and vigour, but is supported by the three pamphlets that I
published on the subject. Not many people can wear such a large anorak
in getting that excited about regulations. I urge the Minister to
consider the amendment as a sensible way to deal with the potential for
over-burdensome
regulations.
Amendment
No. 32 would ensure that the versions of the method statement drafted
under subsection (6)(a) are available to the public in order to deliver
clarity when and if the Secretary of State, who must approve the
statement under subsection (6)(b), alters the method of statement, and
that the public can be
made aware of those alterations. As the Minister is so far unwilling to
remove the somewhat unfettered power that a given Secretary of State
may have over the CQC, we think it important to establish some clear
accountability regarding the influence wielded by the Secretary of
State. I hope that the
Minister can give us some guarantees about the CQC’s not
imposing regulatory burdens above and beyond the national indicator
set. What discussions has he had with the Secretary of State for
Communities and Local Government on that issue, and if he has not
discussed it, when will he do so? Will the draft method statements be
available to the public, and why does the CQC have to report to the
Minister in such a way?
Mr.
Bradshaw:
I think that the hon. Member for Romsey said
that amendment No. 32 proposes that the commission should
publish the drafts of its methodology before submitting them to the
Secretary of State, while not seeking to change the requirement of the
Secretary of State to approve that methodology. I can only assume that
she is trying to ensure that a future Secretary of State does not have
undue influence over the final version of that methodology. At least
the hon. Lady accepts that the Secretary of State has a valid interest
in ensuring that the methodology represents a good measure of overall
performance, and a consistency of approach across the whole regulatory
framework.
I am not
aware of any difficulties with the system as it has been operating
until now, and as far as I am aware there have been no suggestions by
the current commissioner that the existing system has been a barrier to
independence. Instead, it has been found quite useful that decisions on
the methodology between Secretary of State and commissioners have been
agreed through thorough discussion and agreement. I do not think that
the amendment is
necessary.
Amendment
No. 93 would require the Secretary of State to have regard to the
national indicator set when devising or approving indicators of quality
to be used to assess the performance of local authorities. It would
also require draft regulations to be laid before Parliament if further
indicators were introduced in addition to those in the national
indicator set. The suggestion is that that would place an additional
regulatory burden on local authorities, and I assume that the intention
is that the draft regulations would contain the indicators that pose an
additional burden to allow Parliament the opportunity to consider
them.
Amendment No.
137 goes even further and would remove subsections (4) to (8) of clause
42. In their place, it proposes that the Secretary of State should not
set any indicators of quality that are outside the national indicator
set. The problem is that that would leave the Secretary of State with
no power to devise indicators to be used by NHS bodies or local
authorities, or to delegate that function to the Care Quality
Commission. Nor would the amended clause say what indicators the
commission should use in conducting reviews of NHS bodies or local
authorities.
The
amendment would also remove the requirement for the commission to
prepare the method that it proposes to use to assess and evaluate a
body’s performance. It
would therefore remove the requirement for the commission to publish the
indicators and the methodology. That would mean that none of the bodies
being reviewed under the clause would have any information on what the
commission would be assessing them against. We do not think that that
would be a very sensible
outcome. I assure the
hon. Members for Romsey and for Eddisbury that we are committed to
ensuring that there is a joined-up approach in assessing local
authorities. Where the indicators used in reviews under the clause
relate to local authorities working alone or in partnership with PCTs,
other NHS bodies or other local service providers, they will form part
of the single set of national indicators to be used in the new
comprehensive area assessments of local authorities. In that spirit, I
hope that the hon. Lady feels able to withdraw the
amendment.
Sandra
Gidley:
I thank the Minister for his reply. I am reassured
to a certain extent that these proposals replicate existing powers and
that no concerns have been raised to date. In the light of that, I beg
to ask leave to withdraw the
amendment.
Amendment,
by leave,
withdrawn.
Clause
42
ordered to stand part of the
Bill.
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