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Some members of the public were only just beginning to understand what the Health Care Commission and the Commission for Social Care Inspection were about. Three years is not long for an organisation to get established and for systems to start working well, but now this Bill will merge those two bodies, plus the Mental Health Act Commission, into a new regulatory body to be known as the Care Quality Commission. I hope that the best, most experienced people working in those organisations will not be lost in the reorganisation of the amalgamation.

It is hoped that the regulatory body will deal equitably with both the public and independent sectors. There is such variation in the quality of care in care homes. I was once written to by a lady in a home in Leeds. She said that her letters had to be smuggled out otherwise they were read. She was in a room with an alcoholic and her story of the care in that home was deplorable. I contacted somebody I knew who was able to investigate, and sometime later I received a letter from the woman to say she had been moved to a home in Harrogate. She said, “It had been like leaving hell and going to heaven”. I recently met an elderly nurse who was brought up in Ireland and spoke with a distinctive Irish accent, although she said that she was English. She was working in care homes from an agency in Cambridge. One night a lady with Alzheimer's came out of her room and said she was freezing. The Irish-speaking nurse went to the nurse in charge, who was a Filipino, and asked for another blanket as there was only one on the lady’s bed. The nurse in charge said, “Don't bother. The English are always moaning. Go and have your break”. The Irish-speaking nurse, who found another blanket and who really cared for the welfare of those unfortunate patients, implored me to bring up the need for better, kinder care in many of the homes she worked in. She said that nobody listens and nobody cares.

I hope your Lordships will make the Bill more able to give better protection to thousands of vulnerable people who survive behind closed doors. Many organisations for disabled and elderly people believe that it is unacceptable that disabled and old people living in private or charity care homes have fewer legal rights and freedoms than those living in publicly-run residential homes. They want to see the Human Rights Act 1998 extended to cover explicitly all disabled and older people living in private or voluntary sector residential care services. A legal loophole currently exists that means that those homes are not legally bound by the Human Rights Act 1998. I hope your Lordships will support an amendment to the Human Rights Act that will close that loophole. Then perhaps some people who feel that nobody listens will feel that your Lordships do.

When dealing with mental health issues, specialised skills and knowledge are needed. Will there be the necessary training for members of the Care Quality Commission? Many people believe that the CQC should have a clear mission statement enshrined in

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legislation making clear its independence of government. That mission statement would set out clear regulatory objectives and place a clear duty on the new body to drive improvements in the health and social care sectors.

Do the Government want patient and public involvement? First, they closed down the community health councils and set up health forums, which they have also closed down. They now want to set up LINks, which seem vague and unstructured. Volunteers who have been interested in patients’ well-being have been badly treated and many members of those groups must have lost confidence. They certainly feel let down. It seems that once an organisation gets established, it is closed down. Will the duties of the CQC include monitoring the implementation of nutritional standards in hospitals and care homes and ensuring that standards are driven up, health is promoted and that help with eating and drinking is a top priority? So many modern nurses seem to have lost the basic skills of patient care. Good food that tastes good helps patients to get better quicker and it gives them a morale boost and something to look forward to.

The CQC’s responsibilities should include protecting and promoting the interests, health, safety and well-being of the public, patients and users of healthcare and social care services. Many people are concerned by doctors and nurses giving the wrong amounts of drugs and treatments to patients. Recently a nurse working in a hospital in Leeds killed several patients with insulin just because he did not like nursing elderly patients. Patient safety should always come first. There should be a clear statement of purpose in legislation.

One message that has got through to the public is that hospitals are dangerous places because of hospital-acquired infections, which are now also in care homes. The Sunday Times Magazine this week had an interesting article on MRSA and Clostridium difficile. The head of medical microbiology at Stavanger in Norway said:

This is one of the dilemmas that will face the CQC and now we have the first case of the extremely drug-resistant strain of tuberculosis in the UK. I hope that infection control will be a top priority for the new commission. Unless it has adequate funds it will not be able to achieve all its goals.

What is going to be the CQC’s role in the complaints procedure? For years there has been a need for a clear, uncomplicated and quick procedure that people understand. Which? has undertaken research on this issue and found that only half of those with concerns about their hospital care had raised them. Only one in three who felt they had cause for complaint about their healthcare had made a formal complaint. There are many barriers to complaining. Which? is correct in saying that there should be improved communication between providers and patients. This could be achieved by having a panel for service users, patients and the public. This could have a positive impact on regulation.



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Will providers have effective systems for resolving complaints from patients, service users and carers? Will this be made part of the registration requirements? Will the scope of registration—the range of services and organisations it covers—cover all services posing significant risks to patients? Will the Minister ensure that following an investigation the regulator can tackle failure and has powers to make recommendations to all NHS bodies involved, not just the provider where the problem arose? I hope the Minister agrees that safety and quality of care should come first.

7.34 pm

Lord Harris of Haringey: My Lords, this Bill is an important one, recognising that, for those who use them, health and social care should be part of a seamless whole. The Bill provides a welcome opportunity to ensure that the interests of patients and service users are genuinely at the heart of the regulation of providers and professionals.

The service user’s experience is not compartmentalised. Many people will move at various times in their lives, or during the duration of one episode of illness or disability, from one sector to another—from healthcare to social care and back again, or from mental health care to social care. These transitions should be seamless. It is reasonable to expect that similar standards of care should be provided and that the regulatory regime should be comparable. That in a nutshell is the rationale for the merger of these three organisations, which have already achieved much in their different ways with their different remits. Such a merger provides an opportunity for the levelling up of standards and for the best features of each of the three regulatory regimes to be extended to all.

There are, however, dangers. The new Care Quality Commission will have a massive management task in achieving the effective regulation of all the different providers, of creating consistency and coherence across the different areas previously regulated by separate bodies, each with their own styles and approaches. Critical in all of this will be the resources being made available to the new commission. Maybe I am cynical, but I have seen too much legislation passed with many high hopes invested in the new organisations being created as part of that legislation, only to see effectiveness stifled by the nascent organisations being short-changed in terms of funding by their parent departments. I hope your Lordships will agree that the effective regulation of health and social care is far too important to be done on the cheap.

Much has been made of the ethos of the new commission. Ministers have said that involving and listening to users, patients, their carers and the public will be a central responsibility for the new commission. That is as you would expect. It is then all the more surprising that the responsibilities placed in this Bill on the new Care Quality Commission are so weak and watery. Again, it may be my cynical side but I have noticed that some Bills that come before your Lordships’ House seem to be drafted more clearly than others. I come from the school of thought that suggests that if

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you want something to happen it helps to make clear what it is you want it to happen. Alas, in this Bill there is simply no clear statement of the new commission’s core objectives.

The best we seem to have is in Clause 2 and this has a wonderfully mealy mouthed formulation:

Is not one of the concerns that some facilities are in effect being run for the benefit of the people running them? If you are a for-profit provider, are not the activities being carried out to benefit the owners of the facility? Why could not a clearer and more uplifting set of objectives have been set for the new commission? What would be wrong with a simple, direct and clear statement along the lines of, “The Commission shall encourage the provision of health and social care services that are safe, are of high quality and meet the needs of service users”?

There is the rather underwhelming duty—again in Clause 2—to,

and so forth. Why cannot there be an explicit duty on the Commission “in respect of the public, patients and users of healthcare and social care services, to protect and promote their interests, health, safety and well-being, to involve them in all aspects of its work and to inform them about standards of service provision”? The Food Standards Agency has a clear remit,

Other regulators have similarly clear statements of purpose. Why is health and social care to be the poor relation in this regard? I hope that my noble friend will enlighten us when he replies to this debate.

Involving individual patients in the decision-making about their care leads to better outcomes. It is more likely that the treatment or care offered best meets the patient’s needs, the patient is more committed to it and has greater faith in it. As a result, compliance is better as, in turn, are the outcomes. Similarly, if service users, their carers and families are fully involved and engaged in the planning of services, those services are more likely to meet the needs and aspirations of those for whom they are being provided, and the services themselves are more likely to be effective and efficient.

So it is with regulation. The purpose of regulation should be to achieve the best outcomes, and regulators will be more effective in overseeing those things that matter if they are listening to the end users of the service concerned. In this context, the Bill’s phraseology of “to have regard to” is clearly inadequate. The Bill needs to set a clear expectation on the new commission that it will be proactive in seeking out the views of service users and in listening to and engaging with them.



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NICE has established a citizens’ council, whose recommendations NICE must consider and respond to. Likewise, Ofcom has a statutory duty to establish and maintain effective arrangements for consultation with consumers. Again, I ask my noble friend: why are the users of health and social care being short-changed in this respect?

There is, of course, provision in the Bill for an advisory committee, but this will be dominated by providers of service. There needs to be a parallel advisory structure which will clearly articulate the views of service users and the public.

The problem for the present Government is that they have “form” in respect of patient engagement and health and social care. There was the abolition of CHCs. I declare an interest as a former director of their national association. In just a few days’ time, their successors, patient forums, are also to disappear to be replaced by LINks. If the creation of LINks was any more than a fig leaf to obscure the downgrading of patient and public involvement in health, I would have expected it to have a major role in influencing the new regulator. So it was with eager anticipation that I scoured the Bill to find how the views emerging from the new LINks system would be taken into account by the new commission. My scouring was in vain: there is no such mention. If I was not a cynical person, I would have been shocked. So again I ask the Minister: why is there no reference to LINks?

Indeed, would it not make sense to place a duty on the new commission not only actively to seek the views of LINks on the services in a particular locality, but also to report on the quality of the LINks arrangements in each locality, with a power to require the relevant local authority to improve on that quality where necessary?

Let me be clear, the Bill is welcome and will make a positive contribution to the quality of health and social care in this country, but it is a nonsense to suggest that what is before your Lordships’ House contains sufficient to guarantee the aspiration expressed by Ministers that involving and listening to users, patients, their carers and the public will be central to the new commission’s work. However, the changes to make that aspiration a reality are modest. I look forward to hearing my noble friend say that in Committee the Government will bring forward the changes that are necessary.

7.43 pm

Baroness Murphy: My Lords, in my spare time I am a social historian. One of my topics of interest is 19th and 20th century health and social care regulatory bodies from the Madhouses Act 1828. It is fascinating to discover that parliamentary discussions were just about the same then as they are now in regard to these crucial issues. How boundless are the hopes that successive Governments have for the power of regulation, and how quickly hopes are dissipated, often brought about by Governments’ own meddling and reorganisation. The truth is that no regulator can substitute for good management and professional education and we should not have false hopes that the new Care Quality Commission can.



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As we have heard, the new commission follows hot on the heels of the barely toddler-aged Healthcare Commission and CSCI, both organisations having made significant strides in establishing themselves as effective businesslike organisations. Of course we can all find admirable reasons why processes across the health and social care spectrum are sensibly examined together along care pathways, and why some of the new provisions improve the inspectorial work of the Mental Health Act Commission, but whether this justifies abandoning the good work of these three bodies and starting all over again so soon, I am not so sure.

Although I am not a betting person, I would like to offer the House a wager that within three years further debates will be about the reorganisation of this commission because it does not cover the entire spectrum of provision and functions, including financial functions. There is yet a great deal to do.

I realise there is little appetite for opposing the overall thrust of the legislation—let us face it, it seems to be a done deal—but somehow we must ensure that what emerges has the chance of being something other than a new version of the NHS-focused Healthcare Commission. We have debated in this House many times—it has been eloquently expressed again today—the inverse care law, if you like: the hierarchy of socially desirable diseases that places acute medicine and hospital care at the top, social care for older people way down underneath, and lurking even further underneath the social care of seriously mentally ill people and people with learning disabilities.

I was very concerned to see that it has already been decreed that the new CQC will focus on hospital-acquired infection as a number one priority in its first year. That does not suggest to me that the priorities for those most at risk of care failures are going to be considered in that first year. Is that not of serious concern to those interested in the 25,000 units providing social care to the most dependent individuals in our society? Will such patients get a look in? It is a very poor statement of intent for the first year.

Turning to a few specifics—I declare an interest as I was for seven years vice-chairman of the Mental Health Act Commission—I am as concerned as the noble Lord, Lord Patel, to ensure that the Bill affords detained mental health patients at least as good protection for their human rights as the current arrangements, if not better, and I will be supporting amendments brought forward to that end. At the moment, of course, it is all just not clear.

Secondly, I am a board member of Monitor, the NHS foundation trust regulator, which does not figure much in the legislation but plays a crucial role in the regulatory framework of the NHS now that almost half of NHS trusts are foundation trusts. We therefore have a keen interest in ensuring the effectiveness, cost efficiency and total clarity of the regulatory regime. I shall be seeking reassurances about the way the system will work in practice.

I am a keen supporter of the Government’s healthcare reforms and I believe a system of devolved, autonomous and competitive providers from a mixed

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economy can flourish only where there is clear, strong but light-touch regulation. But any lack of clarity in this respect will be disastrous.

Like many people in the House today, I was delighted to hear that the Government are exploring the introduction of amendments to the Bill to recognise the Human Rights Act in relation to residents of private care homes placed there by the public purse. I hope they will also recognise the Human Rights Act in relation to those paying for themselves. As a geriatric psychiatrist I know of numerous instances where older people have been evicted, quite callously, from their places of residence in the face of increasing disability. This flies in the face of the Human Rights Act and has to stop. I hope we will find an opportunity to solve the problem this time round.

I understand the seduction of a universal registration system but in some other countries it has established a lowest common denominator of standards and has not raised the game. I want to be reassured that it will be different here. We need reassurance that registration standards will build on the care standards and the minimum standards currently used by the three commissions. Surely we are not going to register organisations of lesser quality which could not meet these standards. We must build on the improvements that these standards have brought about.

I wish to comment briefly on the fines to be imposed for offences. Even the highest possible fine—£50,000—will have a negligible financial impact on NHS trusts or many private healthcare companies. Can the Minister tell the House how shovelling public money around the system will do the slightest good? I am trying to think how the financially beleaguered Maidstone and Tunbridge Wells NHS Trust would have better addressed its C. difficile problem by being fined £50,000. I cannot see it myself. It was already preoccupied with that problem; it was too busy looking at its financial balance and not busy enough looking at its patients.

One or two other issues complete the picture. I strongly support the Government’s intention that all healthcare professional regulatory bodies use the civil rather than criminal standard of proof, including the GMC, and the proposals for organisations to appoint a responsible officer in cases of fitness to practise. I declare an interest as being registered with the GMC. It would have made my life much easier as an NHS manager in dealing with some of the most difficult cases. The GMC failed to deal adequately with them because of its criminal standard to proof.

I shall probably make myself deeply unpopular with many people in the House, but I question whether it is wise to give extra money to women in the 25th week of pregnancy. I know that it is a popular procedure, but it is a small proportion of people who fail to attend antenatal care. We do not usually bribe patients to take health measures. Given the Healthcare Commission’s recent report on maternity services, I wonder whether it is the best way to spend public money when so much more money is needed to provide continuity of care in midwifery.



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I would like us to be absolutely sure that the powers of intervention in private lives for the sake of public health will be used wisely, and that we have adequate safeguards, appeal mechanisms and independent review for the new powers. I look forward to working on this interesting Bill through its Committee stage.

7.51 pm

Baroness Gardner of Parkes: My Lords, never have I had more extensive or better briefing on a Bill from a very wide range of interested parties. Others have dealt with the important points covered. As a former dentist, I have a particular interest in this aspect of healthcare, and because of limited time, I shall deal mainly with dental topics.

I declare a non-pecuniary interest as a dentist in general NHS practice for 35 years. I was a member of the General Dental Council, elected by general practitioners. Former members of the GDC meet annually. I know that many feel strongly about the registration issue, as I do.


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