| Previous Section | Back to Table of Contents | Lords Hansard Home Page |
We cannot take the risk that important priorities of government and Parliament are left out in the confusion of setting up the commission and the onerous task of registering all providers of health and social care services. The commission will have so many other calls on its time and resources, that I am
25 Mar 2008 : Column 537
As the Bill passes through this House, we should consider carefully what exactly we want it to do. Other regulators have a much clearer mandate and the public can therefore see whether they are doing their job properly. In this area, which is crucial to the lives of all our citizens, it is essential that the new body will be held to account. For that to happen, we need to be clear about what it is intended to achieve. I do not believe that is the case with the Bill in its current form and, in my view, it must be improved in Committee.
8.52 pm
Baroness Meacher: My Lords, I welcome the Government’s commitment to reduce the number of regulatory and inspectorate bodies in the area of health. I declare an interest as a former Mental Health Act commissioner and current chairman of a foundation trust.
I shall focus my remarks on Part 1 of the Health and Social Care Bill and the creation of the Care Quality Commission. I want to talk about the apparent duplication of the powers of the new body and those of Monitor, the independent regulator of foundation trusts. I then want to touch on a few other issues which I hope we shall address in Committee and on Report.
I welcome the fact that the Care Quality Commission will be a patient and user-friendly organisation with a priority to safeguard service users and to help improve their experience of health and social care services. That will build on the very considerable improvements in recent years of the best health providers, and no doubt social care providers, in involving patients in planning services, staff selection and in raising standards across the piece.
I come to this debate from a foundation trust perspective—I want to be straightforward about that. Again, I applaud the Government for introducing a healthcare model which, for the first time in my 25 years in the health service, has significantly improved the quality of services in many trusts up and down the country. It is vital that the regulatory and inspectorate system fully takes on board the implications of this massive change—I would call it a revolution—in the health provider organisational model.
Unlike NHS trusts, foundation trusts have unitary boards accountable to their local constituencies through their locally elected boards of governors. They have legally binding contracts with their primary care trusts for the first time and are regulated by Monitor and inspected by the Healthcare Commission. We also report to our PCTs, and so on. As we know, there are some 53 inspectorates, monitoring and regulatory bodies. The trust that I chair has saved about £15 million in efficiency savings during the past two years simply because we had to become efficient. Monitor demanded that. The degree of waste in the preceding era was
25 Mar 2008 : Column 538
In the previous world of NHS trust status, we lived in a reporting nightmare. I asked our finance director for a note about this because I was aware of his experience. In a single year he had to provide six different, but very similar, annual plans: one to the Department of Health, another to NHS London, another to the strategic health authority as a due diligence exercise, another to Monitor and a further two to different firms of accountants. Each of the plans was based upon different assumptions, leading to different results, requiring different monitoring. You could not even send a duplicate to all six bodies; every single one of these lengthy, detailed reports had to be different. For the DoH and strategic health authority, these returns were monthly. As our finance director said, the work was mind-numbing, thwarted forward thinking, paralysed decision-making and defeated entrepreneurship. “Other than that”, he said, “I suppose it was okay”.
Perhaps noble Lords will understand my anxiety that if this Bill remains unchanged, foundation trusts will face two regulators, Monitor and the CQC, which will have potentially overlapping powers. There will be a lack of clarity. We will once again be in this complete nightmare of duplicating reports and regulation, sending things in different directions, with nothing adding up and every single report being different. There are strong arguments for Monitor to retain the primary regulatory responsibility for NHS foundation trusts. It has proved remarkably effective in raising standards. It was quite painful to meet its requirements. We replaced five board members in order to meet the standards required. The Department of Health has argued that to provide a level playing field, all providers, including NHS, private and voluntary sector organisations, must meet the same standards and face intervention by the same body. Of course, all organisations should, ideally, meet the same standards, if those services can be compared in any realistic sense. I confess that I have my doubts about that. I am not convinced that a small domiciliary visiting service can really meet the same standards, for the sake of argument, as a foundation trust. I am sure that we will return to these issues in Committee.
I turn briefly to the incorporation of the Mental Health Act Commission in the CQC. I have already declared an interest. I am not opposed to this move, so long as the distinctive role and focus of the Mental Health Act Commission in safeguarding the interests of all people detained under the Mental Health Act is preserved. These patients are unique in that they have lost their liberty. They are, in a sense, very much akin to prisoners in terms of how they feel about their health service. They have also lost the freedom to make decisions about their treatment. We know that the Government acknowledge the fine work done by the Mental Health Act Commission. Along with others, I will be seeking a change to the Bill to provide, perhaps, for a mental health sub-committee
25 Mar 2008 : Column 539
A number of people have already spoken about carers, not surprisingly. On Report in the House of Commons, the Minister of State for Health, Ben Bradshaw, emphasised that,
- “the Government believe that involving and listening to users, patients, their carers and the public will be a central responsibility for the new commission”.—[Official Report, Commons, 18/02/08; col. 77.]
Carers UK is rightly concerned that the Bill, as drafted, does not include any measures to achieve this vision. I hope we in this House will ensure that there will be full recognition in the Bill of the role of carers, and the duty of the CQC to consult and involve carers, along with patients and others.
Finally, I turn to two related issues: the need for a set of guiding principles in the Bill—many other Peers have spoken about that—and a clear duty for the new organisation to drive up the quality of service across the country. At present the Bill has neither. Yet the Healthcare Commission and CSCI both have a duty to drive up quality, and the legislation establishing Ofsted and the Legal Services Board both included a strong statement of purpose for the organisations. Why should the Government leave the new organisation with a much narrower focus upon registration and inspection? Having been involved in running the Police Complaints Authority, I remember well that we vastly improved the quality and reputation of that organisation once we started producing reports on the general level of service, whether it was to do with deaths in custody, firearms incidents, the use of CS spray, or whatever. It was really only those reports that began to lift the quality of service across the police services. I am clear that this organisation must have that capacity—indeed, not just the capacity but the duty to provide those reports.
I welcome the Health and Social Care Bill in principle, and believe that with the changes to which I have referred, and the many others suggested by Peers, this could be a fine piece of legislation.
9.01 pm
Lord Smith of Leigh: My Lords, I declare an interest as leader of a local council, and I shall try to reflect those perspectives in my remarks today. I apologise to my noble friend; he must be feeling that with friends like these, who needs enemies? There are lots of things in the Bill that we support but we ought to concentrate on our concerns. I have four, and I am not sure whether they are fully consistent with other areas of government policy.
I agree with my noble friend and many other noble Lords about the need for a supervised seamless service between social services and health. Whether that needs the same regulation because of the differences in culture, I am not sure. Many noble Lords have explored the differences, but one factor has not been accounted for, and I hope that my noble friend will reflect on it. Local government is about to be subjected to a totally new and different inspection
25 Mar 2008 : Column 540
Will the Care Quality Commission, following the reorganisation, with all the potential problems to which noble Lords have referred, be able to support local authorities in this radical change? I hope that it will, but it is possible that it will not. In the debates in another place, the Secretary of State for Health recognised the need for parity with social care, but I hope that we can have something stronger than that statement when the Bill leaves this House. We need to ensure that the new commission is independent, has clear objectives and has a board that reflects its work in its entirety, not just one element.
Part 3 deals with a new approach to public health. We all welcome the modernisation in the Bill, but I am confused about the relationship between this Bill and the Civil Contingencies Act. Section 1 of that Act refers to any event or situation which threatens serious damage to human welfare in a place in the United Kingdom. Any serious public health issue would come under the scope of the Civil Contingencies Act, but the processes described in that Act are radically different from that prescribed in this Bill. There is no involvement of a justice of the peace. Local authorities with emergency and health partners can go ahead and do what is necessary under the Civil Contingencies Act. I hope that my noble friend can end this confusion. If there is a serious occurrence affecting an area’s public health, which Act do local authorities turn to—the Civil Contingencies Act or public health legislation? The procedures are quite different. I remind your Lordships that the Civil Contingencies Act was brought in because of the inadequacies of public services in dealing with foot and mouth or other emergency matters. We need to end that confusion.
I will now do what other noble Lords have done and refer to things close to my heart. Clause 133, in Part 5, places a duty on PCTs “to secure continuous improvement”. I have two concerns about that. First, that clause goes on to say that it is subject to the standards laid down by the Secretary of State. I am never really convinced that improvements in public services are produced by a command and control method. If we want to change the culture of an organisation, we have to encourage innovation, focus on individual needs and encourage localities to respond to their individual circumstances—rather than simply following the lead of the Secretary of State, which by its nature is bound to be generalised. Secondly, reflecting in the 1950s on his creation of the health service, Aneurin Bevan admitted that one of his mistakes was in removing the role of local authorities in health provision. I hope that my noble friend will have the opportunity to correct one of Nye Bevan’s mistakes by asking the Care Quality Commission to encourage pilots that will allow commissioning by a single, local agency—the local authority—rather than assuming that we need the
25 Mar 2008 : Column 541
Finally, I remind noble Lords that in July last year, the Government produced the subnational review, which looked at developing a single, regional strategy for parts of England and improving the scrutiny of regional bodies. I think that while that review left it unsaid, Members of Parliament have assumed that health should be included in that scrutiny. Clearly, health has a major part to play in developing a strategy for a UK region. Its contribution to the economy and social welfare of its area means that it should be a major player in developing such a strategy. Can my noble friend give some encouragement that strategic health authorities could be involved with other regional bodies to develop that regional strategy and be subject to the scrutiny that Members of Parliament will wish to see applied to regional bodies? The Bill has missed an opportunity there.
Given the time of night, I have tried to summarise what I was going to say. My noble friend needs to be in listening mode, not just during Second Reading but at the next stage of the Bill. We can improve this Bill to make something that will stand the test of time.
9.08 pm
Lord Sutherland of Houndwood: My Lords, I thank the Minister for his clear and helpful introduction to the debate and to this Bill. I also apologise to those speakers who followed immediately thereafter, as I had to leave to chair an evidence-taking session of a Select Committee; I have since been back and benefited from many fine speeches. It is late at night and I will try to be brief, but I would like to tell a little story that I hope can set the context for the questions that I would like to put for answer by the Minister either this evening or, more probably, in Committee.
After 34 other speeches, the story has of course been told more than once, but it is late at night and this is a bedtime story; good bedtime stories bear repeating, so I shall briefly repeat. Once upon a time, a long time ago, there was a young, thrusting, forward-looking and joined-up thinking Government that came upon the scene of social care regulation and found it all over the place. Some was being carried out by a variety of local authorities, some through the Department of Health, and so on. However, this fine, young, thrusting Government put through a Care Standards Act in 2000 that swept much of that aside and created the National Care Standards Commission to regulate care services, the public, private and voluntary sectors and private and volunteer healthcare services. That left the Social Services Inspectorate to assess the performance of local councils and social services. That fine, new, joined-up body got going with much enthusiasm, vigour and planning, but after three weeks of operation, the Government announced that it was to be abolished and replaced by the Commission for Social Care Inspection. CSCI incorporated the former Social Services Inspectorate, and started operations in 2004. In the 2005 Budget, the Chancellor announced the creation of yet another new inspectorate to include the functions of the Healthcare Commission, the Mental Health Act Commission and so on, and here we are today.
25 Mar 2008 : Column 542
Here we are once again with a tale of change and mergers. It has been pointed out that mergers are very consuming of time, energy, creative thinking and direction. That tale set in my mind a number of questions. If I were a pessimist, I might see it as a tale of serial meddling or muddling, but I am not a pessimist. I want to join the ranks of the optimists, and we have heard two fine optimistic speeches in the latter stages of this debate. I hope that the Minister can help me move into the mode of optimism by answering the following questions in a way that creates a positive frame of mind. The first question is: have we got it right this time? If we have, how will we know? Can the Minister give an answer to that question that is different from the answers we might have had in 2000, 2004 and in 2005? The Government are very good at setting targets and measures, but what targets and measures will they set for the success of this merger and this legislation? One measure might be a period of stability—if it lasts three weeks without the announcement of a new merger, that would be pretty good going. Perhaps the Minister can give us greater hope than that. Perhaps there will be years rather than months of stability. By what criteria will we judge the success of the proposals before us? Have we got it right this time? What period of stability will we have?
I shall close now as I promised to be brief but how much did these successive mergers cost? Was there huge expenditure on the relocation of staff and the replanning and rekitting of offices, let alone on the notepaper? Oh, the notepaper—how we agonise over the headings! What was the cost in real terms? The real terms costs were the opportunity costs of focusing the energy of some of our brightest and best on merging rather than on regulating and creating care of a high quality. I leave these questions for the Minister to answer to the House.
9.13 pm
Baroness Barker: My Lords, I, too, thank the Minister for his succinct introduction to the somewhat disparate group of measures drawn together in the Bill. I also thank noble Lords all around the Chamber who added the points that need to be said, which could not possibly be said by the Government Front Bench.
When I worked for a major voluntary organisation for older people, one of my colleagues used to say that when the last director of social services would, of his or her own free will, consent to live in a residential home under the terms of a care package funded by his or her local authority, the charity would be obsolete. I am sad to say that that day is not yet in sight, and that is the reason why this Bill, stuffed as it is with tedious organisational detail, is so important.
I now work as a consultant and advise organisations on how to manage strategic change. I often advise them that when they face something called a merger but there is no obvious stated objective and it is not
25 Mar 2008 : Column 543
Why are people so sceptical about this merger? For one thing, it confounds the hope that while permanent organisational turmoil is now the norm for health and social care providers, there might have been a chance for stability and consistency somewhere in a system which is responsible for the expenditure of £105 billion per annum. Sadly, that is not the case. The real source of the scepticism is that the regulator is, as it stands at the moment, to be responsible for regulating healthcare not health. That is an important distinction. This body is going to be responsible for regulating three radically different services, each with a different legal basis. Healthcare is determined according to notional universal entitlements. There are comparatively few providers. Care is free but demand is managed by waiting lists. Mental health is dealt with in much the same way. Yet in social care there is no entitlement nor agreement about what should be provided. There are many different, disparate providers and demand is managed by eligibility criteria.
Without an express objective of this regulator being to improve health, it is inevitable that the commission will focus mainly if not exclusively on acute healthcare. That is easy to manage and can be determined objectively within the short periods that suit political convenience. I have thought all afternoon about what is wrong with this and what the analogy could be to explain it to those watching our debates. I have come to the conclusion that this merger is a bit like somebody in the world of sport suddenly announcing that there would be the same governing body for Formula 1, horseracing and athletics because they are all about getting from A to B.
The big problem is that it is difficult to see how this regulator can work with health and social care as it is now, never mind how it is going to be in about five years’ time. Huge, radical changes are about to take place in health and social care. The noble Lord, Lord Darzi, said in his introduction that his review is due shortly. If, as expected, his main recommendations follow the pattern that he set in his review of services in London, there will be a greater flow of patients between primary, secondary and tertiary care. There will be a greater need to focus on standards of care and patient outcomes in terms not of the institutions where people are but of their pathway and journeys between different institutions. This regulator, perhaps above all, needs to have the function of assessing the flow of patients, patient information and practitioners between different institutions.
In social care there is fundamental change, too. The extension of individual budgets and self-directed care to people who lack capacity and older people is going ahead rapidly. It is incredibly difficult to stand up and criticise individual budgets; they are so important and such an article of faith within certain parts of the social care world. Yet there is a growing
25 Mar 2008 : Column 544
| Next Section | Back to Table of Contents | Lords Hansard Home Page |