| Previous Section | Back to Table of Contents | Lords Hansard Home Page |
One further concession is needed from government—apart, of course, from guaranteeing sufficient resources for what will inevitably be the growing social care side of the CQC’s work. It is argued by Carers UK and others that the CQC should have powers to publish independent reviews of its work without first needing to ask for permission from the Secretary of State, but will the Government have the confidence to grant that? I very much look forward to the Minister’s reply.
8.20 pm
Baroness Greengross: My Lords, I welcome much in the Bill and join in congratulating the Minister on his clear and concise introductory words. I have a few reservations, but I am sure that those and everyone else’s will be well discussed in Committee. I will be very brief; much has already been mentioned. I want to talk about two areas: that relating to self-funders seeking social care, and the vexed issue of human rights. I apologise in advance, with a very heavy head, if I do not make it to the end of the evening; I hope that the Minister will forgive me if I do not.
I was pleased to hear the Minister confirm that the Government were considering how best to achieve the same rights under the Human Rights Act for people
25 Mar 2008 : Column 530
As my noble friend Lady Howe mentioned, the recent Joint Committee on Human Rights report highlighted how vulnerable people in homes can be to lack of respect and dignity, and even to abuse. Of course many homes have excellent facilities, and most provide adequate if not good care, but many give us cause for concern. Malnutrition and dehydration, lack of privacy and dignity, neglect and bullying are just a few of those concerns, not to mention the fear of eviction if a resident or relative makes a complaint, if someone becomes increasingly frail or ill, or if the care home is sold or closed rather suddenly. There is a fairly straightforward way to close this loophole. It could be achieved through this Bill with less recourse to other departments of state—in particular to the Ministry of Justice—than might be the case if we have to wait for a Bill of Rights. If we wait for a Bill of Rights there are many very frail, very vulnerable and very old people who will be dead by the time that Bill becomes law. There should be a duty in this Bill to assess any person entering a care home. Such a person should be assessed either by a GP or by a hospital doctor if they are in hospital or by a qualified social worker. After such an assessment, which would be carried out by somebody in the public sector, the human rights protection would follow that person wherever they go, whether it is to a public, a private or a voluntary care home. I hope that the Minister will consider a government amendment to the Bill to achieve this fairly simple change.
I turn to the issue of self-funders. We are a country of homeowners. Many people have saved throughout their lives to buy their home. Quite a few managed to do so by taking advantage of the right-to-buy legislation. They are not wealthy people but it is very difficult to own a home worth less than £21,500 in this country, whatever sort of home you have. These people are in trouble if they go into a residential or nursing home. Nearly one person in five has to sell the family home to fund a place in a care home. Often they are charged more than other residents who are paid for by the local authority because the local authority can negotiate lower fees than an individual or a family can. The care home can sometimes compensate for those lower fees by charging an extra fee to self-funders and/or their relatives—a top-up or, in my view, an unauthorised tax on those self-funders. That discriminates against self-funders.
We cannot say that two people in adjoining rooms in a care home have different rights, either in terms of their human rights being protected or being treated equally. When working to receive social or health care, it is often difficult to differentiate between what is health and what is social care and what can be funded one way and what can be funded another. People just do not know what they have a right to receive. People who have worked and saved, often
25 Mar 2008 : Column 531
8.27 pm
Lord Lipsey: My Lords, we have heard many expert contributions today, not least from the noble Baroness, Lady Greengross. As it happens I have a little expertise, or knowledge anyway, in this area, both as an ex-member of various regulatory bodies and an ex-member of the Royal Commission on Long Term Care for the Elderly chaired by the noble Lord, Lord Sutherland. But I want principally to contribute a different kind of expertise as someone who has long been steeped in Whitehall life, both as a political adviser and as a political journalist. Two syndromes that I spotted through this long life are relevant to this Bill.
The first is what I would call the “my greatest hits” syndrome, where the Government introduce a Bill, often very heavily opposed, which is thereafter acclaimed to be a success and so goes on the “my greatest hits” list. Whenever a problem in any way analogous arises, a Minister picks it off the shelf and says, “My greatest hit was this. I will do that again”. This Government started off with their greatest ever hit which was the amalgamation of the financial services regulators under the Financial Services Act. Until Northern Rock recently it was proclaimed the most wonderful success. Then nearly as good, they tried it again with their next greatest hit, Ofcom. That was a pretty good success, too. Then—I am cutting the story a bit short—a few years later they tried it with the Equality Commission. It is too early to say whether it is a success. I personally have my reservations but it went on the list nevertheless. So here we are with health and social care. Let us have another greatest hit in the form of a new regulator. This does not mean of course that it is wrong to do this. It does mean that the House and the country should look at this issue with the greatest care because in my experience of popular music, which is even less than my experience of this field, one decade’s greatest hit is the next decade’s greatest flop.
Another syndrome that I identify in the Bill lies in Ministers’ eternal desire, which is true of all Ministers of all parties at all times, to get the best of all worlds. In regulation it has worked like this: all Ministers of all parties, all times and all worlds are signed up to the better regulation agenda, by which is meant the less regulation agenda. However, they find a real difficulty with this. On detailed examination, they find that many of the existing regulations, if not most, are either justified or politically jolly difficult to get rid of. I am thinking of, for example, the way that we are told at one time that the regulations on school trips are so tough that they prevent children being taken to other countries or places where they would benefit from those experiences, and then some poor child suffers a misfortune and the same people explode into print, demanding tougher regulation to make sure that it does not happen again. So what is a poor Minister to do?
25 Mar 2008 : Column 532
In the field of regulation, the answer is that if you cannot get rid of the regulations, get rid of the regulators. So the present Prime Minister, as Chancellor, announced a big cut in the number of regulators, of which the Bill is one fruit. Again, that does not make it wrong, but it means that we should look at it with particular care. Legislating by rote law is not a good way of legislating. When we do, we find a great flaw, such as that that lies at the heart of the Government’s case for this Bill—at least for Part 1. The Government rightly point out that health and social care must come more closely together. The noble Lord, Lord Sutherland, and I have advocated that for years. But from that the Government leap to the conclusion that the two should be regulated in the same way and that the regulations should come more closely together. Regulating healthcare and social care are very different activities.
Noble Lords should think about what is required if you are regulating a large hospital. You need data, facts and figures, statistical risk-assessment—for example, comparison of whether one hospital is doing better than another regarding its heart bypasses—and you need ultimate sanctions such as closing down the bloody place if it is failing. That is how health regulation works. Think what is required if you are regulating, say, a residential home for four elderly people, run, as many are, by an ex-nurse. Of course you need to be firm, but you need also to be flexible—to educate rather than instruct; to incentivise rather than penalise; and to help people achieve a higher standard. Remember that the ultimate sanction of closure may be all right for a hospital but is not all right for old people’s homes, because the evidence is that old people die if you move them in their extreme old age.
I am reminded, too, of the Government’s previous venture into regulation in this field—the regulation of old persons homes. It stands out in my mind. I remember a proposal to metrify that Bill, whereby a room with two elderly people should measure at least 10 metres by 10 metres, instead of 10 yards by 10 yards, until it was pointed out to the Government that this measure would close a large number of uneconomic old persons homes up and down the country. The Government eventually backed off. Thank God they did, but that does not exactly reinforce one’s faith in the Department of Health as a regulator in this field.
Anyone reading this Bill will see the emerging dominance of the health mode within it. Healthcare will run the show. As the briefing on this debate from Action on Elder Abuse states:
“There must be a retention of an inspection regime that carries out personal inspections and visits to services, rather than a data-trawling and survey-led approach as is currently used in health regulation”.
We should consider also the costs of reorganisation. I was brought up in government in the 1970s in the Department of the Environment, where the mantra was: “If there is one thing worse than local government reorganisation, it is local government re-reorganisation”. This is not a reorganisation, nor is it a re-reorganisation. It is a re-re-reorganisation—the third since 2002. The National Care Standards Commission, recommended
25 Mar 2008 : Column 533
In conclusion, we should have one test and one test only for this Bill—will it improve services for users of healthcare and social care? Some of us believe that the case is not proven and that the legislation is therefore palpably premature. At the very least, big changes will have to be made to the Bill in this House—with ministerial agreement if possible; with the votes of your Lordships if not.
8.35 pm
Lord Adebowale: My Lords, I apologise to the Minister for missing the start of his speech. Perhaps my next sentence might explain why I was late. I declare an interest as the paid chief executive of Turning Point, which promotes health and social care and social enterprise and is regulated by the Commission for Social Care Inspection, the Healthcare Commission, the Housing Corporation, the Charity Commission, the Audit Commission, the Housing Inspectorate and the National Treatment Agency. I start by saying that if there is any possibility of regulation that can make sense of my day, I must support it.
In supporting the Bill, I point out that all change involves huge risk. If one is too risk-averse to attempt any change, then nothing happens at all. The issue is whether this change is worth the struggle. Is it worth the struggle for those people who are not in this Chamber? I speak with my mother in mind. She has been poorly for some time, she has been seeing a GP, she has been in hospital and she may well need social care. Having done battle with various parts of the NHS and social care system on her behalf, I have to say that it is worth struggling for a joined-up health and social care system. I think that it is worth the struggle to have one phone number instead of 100, and I think that it is worth the struggle in the interests of those people who need a clear route of complaint and of redress.
That statement is somewhat visionary and I have listened for some time to a number of noble Lords commenting on this Bill from a position of—how shall I put it?—gentle scepticism about whether the Government are going to achieve that vision. But I believe that we must try. I say that with due regard to the excellent work of the Commission for Social Care Inspection and the Healthcare Commission, with which I and my organisation work closely. But I see the gaps between those organisations reflected in the unmet needs of many people. I also note the many comments pointing out the risk of social care being rolled over by the huge behemoth of clinical care and the NHS. I have much sympathy with that view and I have often argued with the Minister for social care to have a much greater role in his thinking on NHS reform. The Bill needs a much greater guarantee of
25 Mar 2008 : Column 534
It is probably worth summarising the concerns that have been expressed so far. I apologise if I do not do justice to everyone’s comments but I think that there are three main concerns. One is that—certainly in relation to Part 1, which is where most of my remarks are focused—we will not keep pace with change, the risk being that the new regulatory framework will take insufficient account of the transformation and change in service provision, patient pathways, customer care, client needs, service user involvement and engagement. That is a real concern, which is not reflected in the Bill.
A second concern relates to size, scope and disparity—that is, that the differences in scale, scope, character and accountability within health and social care and mental health will not be reflected in the new regulatory framework. Again, there is much work to be done on the Bill to ensure that those things are integrated within the regulatory framework.
The third concern is: where is the benefit to service users clearly expressed in the Bill? People talk about values and principles being set out in the Bill but I prefer to talk about the need to express in the Bill the vision and values of customers or users. It seems to me that those concerns are still valid and it is on those that I base my meagre contribution to the debate.
One concern with which I have some sympathy is that the role of commissioning is not mentioned in the Bill. We spend £90-odd billion on health and social care in this country, most of it through the process of commissioning. Commissioning is the means by which you understand the needs of an individual and/or the community in which that individual lives and thus provide the platform for procuring health and social care services. If you do it badly, believe you me, no amount of regulation will help—I have seen it. All those health and social care deserts are not necessarily the result of a lack of funding; they are the result of poor commissioning. Therefore, frankly, I am amazed that commissioning does not form part of the Bill.
I am equally amazed at the advertisement for the chair of this new regulatory body. It has been said that a signal is being sent by this advertisement and the salary for the post. Surely a mistake must have been made, in which case the signal is that not enough thought has been given to the Bill and to the leadership that is necessary to put in place Part 1. Alternatively, thought has been given to those matters but they are not considered to be as important as, say, the Audit Commission or the FSA. I, for one, beg to differ.
Finally, I support the comments of the noble Lord, Lord Patel of Bradford, regarding mental health. I happen to advise the Minister on delivering the race equality programme and mental health. The impact of mental health on black and minority-ethnic groups is disproportionate and severe. It goes unnoticed and is a national disgrace. Despite the concerns and critiques that I have heard, the Bill provides an
25 Mar 2008 : Column 535
Therefore, once again, we are at a tipping point between an opportunity and a risk. On the one side, there is the risk of complete and abject failure, because I suspect that the Bill will go through to achieve a vision for my mother and people such as her. On the other side, we have an opportunity to create a world-class beacon of regulation and inspection that will make my daily life easier—I said that I had a self-interest—and, more importantly, to ensure that people not in this Chamber get better care outcomes and better value for money.
8.44 pm
Lord Pendry: My Lords, the trouble with having one’s name pulled out of a hat and finding oneself number 33 on the speakers list in a debate of this kind—although I am not sure that it is that scientific—is that most of the points have already been made. If I repeat things which have already been said, please forgive me.
I welcome the Bill and the setting up of the Care Quality Commission. It is a clear attempt by Government to improve the health and social care system through a single, regulated body. It also addresses the important role of those who work within the system. The Bill will also do away with many outdated provisions that are currently in place which many within the system would argue are no longer appropriate to meet the needs of both patients and service users.
The new Care Quality Commission, to be created by the Bill, will replace the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission. As has already been pointed out by the Minister, this rationalisation is a sensible move forward but, by itself, I stress that it is clearly not enough.
It is far from clear that the new regulator, as it is spelt out in the Bill, has a clear enough framework by which to judge the effectiveness of the commission in its operation. For instance, will the commission have the specific objective of promoting provision of health and social care services that are safe, high quality and will meet the service user’s needs? One could talk about the protection and promotion of health, safety and well-being of the public, patients and users and so on for some time but a lot of those points have already been stressed in the debate, so I will not go down that path.
Having separate systems for health and social care has created confusion, so the fusion of the services working together could be a good thing. Regulation can help the process of delivering what the other services wish to bring about. Although the Bill deals only with the regulation of health and social care, I suggest that we must consider it in the context of other pieces of legislation in this area which have
25 Mar 2008 : Column 536
The Carers and Disabled Children Act 2000 enshrined the right of carers to have their own needs assessed independently of the person they care for, regardless of whether that person had had an assessment themselves. This is an important principle. It ensures that carers are viewed as individuals in their own right, something which carers feel very strongly about, and rightly so. The Act also gave local authorities the power to provide services directly to carers. Councils in England now provide an average of 20,000 holiday breaks to carers each year.
My Act was the second of three Private Members’ Bills concerning carers which became Acts of Parliament. The first was the Carers (Recognition and Services) Act 1995, introduced by Malcolm Wicks MP, and my 2000 Act was further strengthened by the Carers (Equal Opportunities) Act 2004, introduced by Hywel Francis MP. It stated, among other things, that local authorities must inform carers about their right to an assessment.
As well as assessing and providing services to carers in their own right, councils are starting to do better at recognising the vital contribution that carers make. Most care to elderly and disabled people is provided by carers, not by professionals. We still need to go a long way in truly recognising carers within our society. Although I believe that the Bill has good intentions, I equally believe it needs strengthening. There is a danger that because carers are not mentioned even once, it could mean that the good work being done by the Government—namely, the New Deal for Carers—might be a casualty of the Bill. Perhaps giving local authorities and health services additional requirements on carers outside of the provisions of this Bill might undo some of the good work that has been done by the three carers Acts to which I referred and which are now on the statute book. It is true that in another place Alan Johnson, the Secretary of State in charge of the Bill, implied that the new commission would have responsibility for involving and listening to carers. I am sure that he was in earnest when he made that statement, but it is not shown on the face of the Bill. The commission must have that pledge written into the Bill for it to have real meaning. I hope that it is not too much to expect that, with all its good intentions, the Bill would be further strengthened by such an inclusion rather than rely on secondary legislation.
| Next Section | Back to Table of Contents | Lords Hansard Home Page |