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I describe myself as a former dentist because the opportunity of calling myself a “retired dentist” or a “non-practising dentist” was taken away from me in 2004, when I was told that the age-related reduced fee of £65 was abolished and that, unless I paid the then new fee of £388, which represented an increase of 122 per cent, I would be struck off the register. It was estimated that 2,500 dentists were struck off at that time, although most of them would willingly have paid £100 to remain on the list. These lost fees would have given the General Dental Council an extra quarter of a million pounds. It also soon became obligatory to carry out continuing professional development involving courses and study, even if one never wished to treat a patient again.

The General Medical Council is entitled to hold a list of non-practising doctors on its register. It makes very clear whether a practitioner has a past record of good practice. In 2004, when the change in dentistry took place, the GMC made no charge to the retired doctors on its list—I do not know whether it remains free.

One could be struck off the dental register either for misconduct or simply because one no longer wished to continue in practice. This lack of distinction between the honourable and the dishonourable absence from the register is invidious and upset many dentists. I took it up with the GDC at the time of my leaving and again last week. I am told that it no longer sends letters stating you will be “struck off”; it now says that “your name will be removed from the list”.

It is possible the GDC may not wish to have such a list, and if so, has been hiding behind the lack of legal powers as an excuse. The person to whom I spoke raised the point that dentists who wish to remain on the list as not practising may be doing so for their own personal reasons and not in the public interest. It is a good point.

I know that I have a personal interest. I recall my father, who was believed to be the world’s only Minister for Health and Motherhood—in the New

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South Wales Storey Government—paying his registration fee as a pharmacist to the day he died.

I was interested in the health in pregnancy grant. I would like to hear more from the noble Baroness, Lady Murphy, about her point on that.

There is a public interest in non-practising dentists remaining on the list, as many non-practising dentists continue to work on boards, trusts, charities and other bodies, public and private. If they claim to have been dentists with an honourable record, it should be verifiable. I was vice-chairman of North East Thames Regional Health Authority and later chairman of the Royal Free Hampstead NHS Trust after I had ceased dental practice. Had the age-related registration which I enjoyed not applied at that time, no one would have had any idea of my dental status.

The General Dental Council might also wish to consider some difference in fee for those dentists who do not wish to practise at all, but who are employed in some capacity that requires them to retain registration. At the very least, people who carry on little if any dental treatment for patients should be allowed to pay in instalments rather than having to produce the full £438 at the beginning of the year.

It is surprising that there is no mention of dentistry or the Dentists Act 1984 in the Bill. It brings to mind the Sherlock Holmes dog that did not bark. The president of General Dental Council referred in his winter message to a,

emerging when a,

I am sorry to see that a fully appointed council is proposed as I thought it very healthy and desirable that a number of dentists were elected by their fellows. I am disappointed that the General Dental Council does not appear in the Bill, when the General Medical Council and the General Optical Council do so.

I have always been told that the General Dental Council lacked the legal powers, which exist under medical legislation for the GMC, to have non-practising dentists on a separate list. The dental legislation was claimed to be defective. As I doubted the accuracy of that remark, I wrote to the Department of Health, which confirmed that a change in the law would be required.

Looking at the changes proposed under Clause 60 of and Schedule 8 to the Bill, I am convinced that, had the GDC wished to make changes, it could have applied at any time under Clause 60 of the Health Act 1999. I intend to bring forward an amendment in Committee. With these powers, the GDC would have the right to make a decision, which it claims is presently denied to it. Is it just hiding behind the Government and a legal technicality?

In his winter message in the GDC Gazette, the president mentions that from 1 August continuing professional development will be compulsory for all dental care professionals. He states:



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This must be good, but it is important that some flexibility is applied. I took the point made by my noble friend Lady Cumberlege.

Until the first registration date, anyone who is working as a dental nurse is entitled to registration on the basis of their experience, but, after that, they will have to have a qualification. When I was in practice, dental nurses, then known as chairside assistants, were trained on the job. The dentist was always fully responsible for his or her staff and their actions. Some went to evening classes and got extra qualifications, but they were optional, not mandatory. Running a dental practice is like running a small business, and there are always holidays and sickness periods when additional cover is needed. There were instances when some of my children, on school or university holidays, stepped in to fill these gaps. Now the BDA News tells me that even if a receptionist covers only lunch breaks amounting to two hours a week, they will still need to be registered and that the registration fee is more than £90. Some practices use probationary periods, but they will all have to pay a registration fee. I can remember when there was full employment and it was extremely difficult to get anyone to work as a chairside assistant—it is not a job that has an instant appeal and it is quite hard work. I am concerned that the time might come when it will be hard to attract enough applicants. To have proper well trained dental nurses is good for everyone: for the nurses who will have achieved a high standard, for the dentists they work with and for the patients. How can we ensure that we have enough of these qualified nurses? I suppose that agencies play a part, but that is not the ideal answer. The dentist has a medico-legal requirement not to treat patients unless another adult is in the surgery with them, because they can be accused of attacking the patient, for which I have seen dentists struck off. What will the dentist do if his nurse is ill and there is no one to step in? Will he simply send the patient away, even though he or she is in great pain? There must be some degree of flexibility in these things.

Sixth formers came to our practice for work experience. Indeed, the splendid dentist who looked after me last week decided on her dental career after such an experience. What legal provision will there be for young people to work in a dental surgery or any other health field as work experience to see whether they would like to enter these professions?

I have run out of time so I shall not continue. I served on a GDC disciplinary committee, and I served as a national health adjudicator. I welcome the fact that now dental treatment, private or national health, will be able to be inspected, as we saw cases where there was wonderful national health work done, but we could not comment on the atrocious private work done by someone, who admittedly was dying, so I hope it was not typical of his work. It meant that for people doing private work, no patient had any way of seeing whether they were right or wrong.



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I agree with the civil level of proof that has been mentioned. I thought that the noble Lord, Lord Carlile, made a very interesting case for legal or non-legal chairmanship. The noble Lord, Lord Walton, made a particularly important point in saying that wherever a case is being heard someone with specialised knowledge of that particular aspect of medicine should be on the board. I know of cases currently under way where that is not the case. The GMC is conducting cases without anyone specialising in the field alleged against a particular doctor. It is always good to move to a higher level in standards and training, but there must be flexibility.

I hope that the Bill will operate effectively and do much to help patients and their families. The Healthcare Commission, when referring to Clause 16, said that,

I think that that summarises my view.

8.02 pm

Lord Harrison: My Lords, as the noble Baroness, Lady Finlay of Llandaff, ran past me on the Underground, I, too, feared that I would not be in time to hear the complete speech of my noble friend Lord Darzi in his opening address. I genuflect and grovel that I have to apologise for not hearing the whole of his speech.

However, my time down from Chester today was usefully employed by talking to the Reverend Brian Holroyd of the Chester Abbeyfield Society which provides home care for older folk. He tells me that the noble Baroness, Lady Bottomley, is a marvellous chairman, and that he looks forward to welcoming the noble Baroness, Lady Neuberger, tomorrow when she addresses the Abbeyfield Society.

I enter this field of which I am largely unknowledgeable. The Care Quality Commission brings together social care and the National Health Service, and I fear that the social care element will lose out at the expense of the National Health Service. I am also concerned about the role of small businesses in the social care area. While the care sector is, unlike the health service, a small independent sector organised for the large part, it is absolutely essential that the new CQC is able to differentiate properly between the sectors in its regulatory activity, and to accept that the two sectors are not cut from the same cloth. Indeed, CSCI notes in its State of Social Care Report for the years 2006-07, published in 2008, that there are some 80,500 care homes for adults of all ages, with more than 4,500 domiciliary care and nurses agencies registered with the commission, and a further 133 adult placement schemes around the country.

There has been a slight decrease in the number of care homes—there are still 442,000 places—but there has been an increase of 112 home-care agencies over the past year. That adds up to about 24,000 services employing care staff. Most provide care directly, some organise care, and some do a combination of both. The essence to understand is that three in five are very

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small—that is, they employ 10 people or fewer—and one in three is small, employing between 11 and 50 staff. Some 13 per cent are of a larger nature.

Over recent years, there has been some consolidation in the care-home market resulting in fewer homes, but with the same number of places available. Just four operators own some 80,000 places out of that 442,000, compared to 10 operators in 2004. Yet again it should be noted that the remaining providers provide 70 per cent of the work. They are defined by having fewer than three homes.

The CSCI publication on domiciliary care, Time to Care?, likened domiciliary care to a cottage industry. The domiciliary care sector is predominantly run by small providers, often highly dependent on a small number of council contracts. That has an impact on the workforce because, although found in smaller enterprises, it is as large as that found in the National Health Service. I hope that the Minister thoroughly understands that. Indeed, according to the Skills for Care 2008 report, there are something like 1.4 million people in paid employment; 1.3 million directly employed; 78,000 who were “bank”, “pool” or agency staff; and some 100,000 people employed by recipients of direct payments.

In contrast to healthcare, social care in the voluntary and private sectors is provided predominantly by the independent sector. It employs 70 per cent of that 1.3 million workforce; councils employ something like 16 per cent; and the NHS employs some 7 per cent.

The age range is varied; 57 per cent of the workforce was aged 30 plus when they first worked in social care; and 32 per cent were aged 40 plus when they started in social care. So they come in relatively late. Social care is often seen as a sector with a very high turnover—60 per cent of the workforce has been working in care since 2000, but 40 per cent started before that, with 13 per cent starting before 1990.

This all adds up to recognising that the sector of social care is differently composed from that of the NHS. If this commission is to bring the three previous commissions together, it is imperative that it recognises those differences exist. So one of the questions to my noble friend is this: when we have the Care Quality Commission, what efforts will be made to ensure that its members have knowledge of those different sectors? What is important is not just the sector that will require inspection of the various enterprises that find themselves there, but a sensitivity to those who run these small businesses. Not only are there the problems associated with the fact that these are small enterprises and therefore sometimes more vulnerable to the requirements to be properly inspected and brought up to full value and full standards, but there must be some sympathy to the understanding of those who are providing within that sector.

Likewise, is the training of the staff who are going to inspect in this area adequate? Are we sure not only that they can spot the problems, but that they can be sympathetic to some of the real problems that emerge in that sector from time to time? Is the Minister happy

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with the expertise that he hopes to bring within the commission—that it will be able to fully recognise that small business sector?

I, like others, think that a clear statement in the Bill of the regulatory objectives would be useful in many ways, not least so that the independent sector organisations understand what standards they have to recognise and live up to if they are to fulfil what we require of them.

I shall end on the need to ensure that the human rights of people who find themselves in these smaller care homes and with care agencies and so on are respected. It has been brought to my notice that there is a loophole in the human rights legislation, which perhaps takes away some of the rights that those in the care system should be enjoying. Is the Minister content and happy that where a complaint is registered in, say, a smaller home, those who are not satisfied with the answers that they get in the first instance can ask the question higher up the ladder so that they ultimately get satisfaction? I hope that with those points in mind, and a reiteration that the workforce is as represented in the social care sector as it is in the healthcare sector, the Minister can go forward with the Government’s plans, to which I would otherwise give a generalised welcome.

8.11 pm

Baroness Howe of Idlicote: My Lords, the Bill has clearly attracted considerable attention and with that in mind I shall try to confine my remarks to one or two issues only. I apologise to the House if other noble Lords have already more than adequately dealt with these, but with the number of Bills currently going through the House, and other essential meetings to attend, it has not been possible to be present in the Chamber for as long as one would have wished. It is clear, too, that, as well as the criticism that the House has heard today, there is support for what is seen as the Bill’s potential to deliver a more joined-up approach for health and social care regulation, and for its attempts to remove some existing unfairness; for example, the liable relatives rules. However, even on that issue, the charities and specialist organisations involved remain concerned that some local authorities are not giving the relatives of handicapped or elderly patients the help or the choices of help that they may be entitled to.

The proposed new regulator—the Care Quality Commission—while welcomed, is criticised by a number of organisations. We have been beautifully briefed by those organisations—Which?, the National Consumer Council and the Picker Institute among others. The main concern, as many noble Lords have said, is that the new regulator is not being provided with a clear set of regulatory objectives. Some progress was apparently made on that point in the other place. However, the phrase “have regard to” patients’ views is seen as far too passive and unimaginative an approach.

What is needed, it is argued—with considerable justifications, I, like other noble Lords, would have thought—is for the new commission to be given a

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duty in the Bill to engage with and involve service users during its regulations and inspections. As my noble friend Lady Masham of Ilton has mentioned, Which? has also argued that the CQC should be required to appoint a separate independent—and I stress independent—advisory committee of service users and members of the public, including carers, which would help the regulator choose themes for reviews and set priorities. Perhaps it would be something along the lines of Ofcom’s consumer panel, which does just that. The Picker Institute and a number of other charities, as the noble Lord, Lord Harris, has said, point to the contrast between the Government’s intentions for the CQC and for the three other new regulators created since 1997, where user interest also required strong protection.

I return to Ofcom as an example. Its principal duty is stated at the top of the Act; that is, to further the interests of citizens and consumers. As someone much involved with the Communications Act 2003 and subsequently as a member of the House of Lords Communications Select Committee, I can tell your Lordships that hard-fought-for addition to the Act—and, not least, its acknowledgment of citizens’ and consumers’ somewhat different interests—has had a profound effect on that regulator’s subsequent work and priorities.

As the noble Lord, Lord Harris, also said, it is not just Ofcom. The Financial Services Authority also has its four regulatory objectives printed at the beginning of the Act, which again focus on end-user interests. Similarly, the Food Standards Agency, set up in 1999 has its main purpose set out at the beginning of the Act, which is, “to protect” the public,

In light of all this, I hope that the Minister will be able to give the House some encouragement that the Government are undergoing a change of heart, particularly as other Members of your Lordships’ House have mentioned it so many times.

The other major issue that I wish to mention and support is the concern raised by Age Concern, Help the Aged, Radar, the RNID, the RNIB and many other organisations over the Human Rights Act. The fact that this Act currently does not protect the elderly and disabled living in voluntary or privately run homes, which currently cater for some 90 per cent of those needing this kind of care, is, I would have thought, a huge concern. I am sure that, like me, noble Lords will have visited homes that deliver excellent, loving care. However, your Lordships will also have read in the press appalling stories of ill treatment and seen the recent disquieting report from the Joint Committee on Human Rights which, I am afraid, highlights that excellent care is far from universal.

I hope that the Minister, when he replies, will be able to confirm unequivocally that the commitment given by the Minister, Ben Bradshaw, in another place that all private and voluntary sector providers will be brought securely within the ambit of the Human

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Rights Act. I think that he has given some indication that he is going to be able to do that at the end of progress on the Bill.

I would like to end on a more general note. I confess to not being a totally enthusiastic supporter of what I call the giantism blueprint for regulators of the noble Lord, Lord Carter of Coles, which has been applied by the Government to almost every aspect of public life. He has managed to achieve that by getting the Government to merge existing regulators in a particular field into a single, giant body. Ofcom and the Equality and Human Rights Commission are two good examples.

In this case, as we have heard, the Commission for Social Care Inspection, the Healthcare Commission and the Mental Health Act Commission are to be merged to form the CQC. There is special concern here because it is the third such proposed change for the national regulation of social care since 2002. Somebody suggested that it was the fourth, which would be even worse. CSCI has done a huge amount of valuable work on the rapidly growing social care side of things, and its view is that another structural change in the regulation of social care and health services is premature; that view may be understandable. However, as was said by my noble friend Lady Murphy, this looks like a done deal. Many involved can see potential benefits from having a closer working relationship between health and social care. However, it is crucial that both be seen as equal partners. Just as those with responsibility for disability rights were reluctant to join the Equality and Human Rights Commission until satisfied of an equal standing with race and sex equality, so this will be crucial for the CQC. Organisations have stressed—I quote Carers UK—that:

its work is “not dominated by health”.


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