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The most important area as far as this is concerned is that of detaining patients in psychiatric hospitals, which I happen to know little about. The Mental Health Act Commission’s work will now be involved in the CQC. As the noble Earl, Lord Howe, mentioned, these patients have their rights taken away. They have treatment without their consent—about the most unpleasant thing, if you really put your mind to it, that can happen to anybody. They are told, “You will have this injection. You don't want it but I can't be too concerned about that. You will have it”. Many of them are not allowed to leave the ward. They are de facto prisoners. That is a completely different set-up from the average health or social care person.

I will not say any more about the Mental Health Act Commission. The noble Earl, Lord Howe, has spoken eloquently and I know that the noble Lord, Lord Patel, will also speak at length about that, so I

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simply want to refer to the Healthcare Commission having taken on board itself a degree of patient, service user and carer involvement. How else could it presume to monitor and assess patient focus? I know all too well that that is one of its core standards. I have just been reading our own response to the Healthcare Commission, which is all about patient focus. How can it do that work properly without user involvement?

The Government may ask why we need this amendment if current regulators are doing quite a bit of this already. My response is that the Bill as it stands and government statements reveal confusion between listening to the views of the public on the one hand and involving people, users, carers and families in the provision of services on the other. It is a completely different thing. I acknowledge that the Government's response to the pre-legislative consultation in 2007 was encouraging, referring as it did to involving service users. But in response to continuing debate about this issue, the Minister proposed a government amendment producing the following wording in Clause 2:

I think I am right in saying that the words “or on behalf of” were added after deliberation on the Bill in the other place. The Minister in the other place then said:

Testing public views through organisations representing patients and service users is helpful, but it is not a substitute for involving the patients, service users and families in the process of regulation as proposed in this amendment.

Clause 2(3)(a) simply does not deal with the issue that we are debating here. It goes some way, but it is a long way short. Looking at the history of the health service, I suggest that the Bill as currently drafted details what we have been doing for 40 years. We suggest that we have moved way beyond that, as other Members of the Committee have said. However, the regulator now needs to catch up with what other organisations are doing.

I have also tabled Amendment No. 104. This amendment presents a more limited requirement for CQC inspection teams to include lay inspectors—families, carers, users—in their inspections. This is an alternative, more limited amendment and, in my view, it focuses on the crucial bit, which is the inspections. For me, the crucial point about Amendment No. 27 is that it spells out the absolutely key activities—not just one, but a few others—where service users, carers and families really need to be involved if they are to do a good job. I hope that the Minister will agree with the principle proposed here.



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4.30 pm

Lord Patel of Bradford: I remind the Committee that I have an interest as chairman of the Mental Health Act Commission.

I am encouraged by the Minister's previous expression of openness towards further discussions on the question of service-user, carer and general public involvement, especially in the work of the Care Quality Commission. I have put my name to Amendment No. 27, which I think sets out duties for such involvement in a meaningful way. It is, at least, a great improvement on the Bill's construction as presented, which only requires the CQC to “consider the views” of service users and others. A duty to consider the views of service users may be too easily met by consultation, rather than involvement, as many noble Lords have pointed out. I would want an organisation that is required to have service users at its heart, not on its periphery.

The Minister has previously paid tribute to the Mental Health Act Commission's service-user reference panel, as have other Members of the Committee on a previous amendment. The Mental Health Act Commission has always had service users among its membership, but in recent years it has made particular efforts to involve service users who are or have recently been detained, which has had a huge impact on all aspects of the organisation, not just on the visiting programme. Last week, we published a report which I know has been sent to the Minister.

The involvement of service users is something that everyone is keen on but, if the truth is told, very few organisations do it well. Many do little other than consult their service users. Consultation is, of course, a good start but it does not go far enough; it does not engage people in any meaningful way. In my experience and in the experience of the Mental Health Act Commission, real service-user engagement is very challenging. It involves a huge number of risks that managers and staff have to take. It requires resourcing which includes not only staff time—named individuals who take the work forward—but also sufficient funds to undertake the work. Only when the Mental Health Act Commission has put in those resources and individuals to do that work will a real impact have been made. It requires understanding and commitment from the whole organisation. People need to be trained and they need to own the vision. That should not be an add-on or an extra but at the heart of what it does. It is very challenging and should be underpinned by some systematic and proactive approach. We tend to be very reactive when things happen, but we do not have a systematic approach to dealing with this. They are the key elements of what needs to happen.

The rewards are significant. True engagement with effective service-user and carer involvement enables us to understand who people are in all their complexity. It is a truism, but important none the less, that services would not exist if people did not require help, support and treatment. The service exists for the service user. Sadly, that may not always be obvious, but it is the service user who is the expert, for example, on how it feels to be detained against his or her will; to be denied many things that we might take for granted in our

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day-to-day lives; to be treated with powerful psychotropic medication. Service-user involvement is not a luxury to be added when we have the basics right. It is the basics. The Care Quality Commission must be able to draw on that experience and expertise, to tailor its visits to those matters that service users themselves identify and to ensure that the civil legal and human rights of patients are upheld at all times.

It is essential to the current government agenda of increasing personal choice and ensuring that services are responsive to individual need and that they start to become user-led. The really important point is that the Care Quality Commission must be a leader in this if it wants to inspect how others develop service user and carer engagement. It needs to set the benchmark. It needs to get its own house in order and show the way forward as regards principles of equality and engagement and inspecting others. For too long, professionals, academics, practitioners and managers have retained sole control of organisational priorities. I would want to see the CQC’s technical commitment to service-user and carer involvement fully on board so that this becomes one of the key drivers of policy development and implementation at every level.

We can see the evidence of this in the Mental Health Act Commission, where service-user involvement is not only about having an effect on the patients that it visits, but about changing the culture of the organisation. Commissioners who work alongside service users have reported that experience influences the way in which they carry out their duties. It is important that this cultural shift is preserved by the CQC’s monitoring of psychiatric compulsion and that service-user and carer involvement is entrenched in every aspect of its work, too. I hope that that will be emulated across the CQC, and in support of that aim I support the amendment.

Lord Lipsey: I support the amendment proposed by the noble Baroness, Lady Barker, at least as much for what it leaves out of the Bill as for what it puts into it. Under subsection (3)(a), every time a drunk who is being stitched up in A&E says, “This place is a shambles”, that will have to be reported to the commission so that it can have regard to it. Indeed, when he says, “Cor, God bless, you lot are angels”, that, too, will have to be reported to the commission.

Of course I exaggerate to make the point, but it is not right to take casual remarks of members of the public as though they were equal to a more considered process. In support of the amendment proposed by the noble Baroness, whether the rest of it is right or not, the phrase “engage with” is at the nub of the problem. We need a degree of dialogue and of mutual understanding. That is not just a question of having regard to some grand body up there saying that this or that sounds good, but of communicating in a two-way direction. That is what in the modern world the noble Baroness said this kind of consultation involves. I would like to see the Bill amended to reflect it.

Baroness Knight of Collingtree: I would like to ask the noble Lord, Lord Lipsey, a direct question. Who would decide what was a remark that should be taken note of and a remark that should be ignored?



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Lord Lipsey: Presumably, the commission will have to have regard to the Bill and give instructions as to what is to be taken on board. I can imagine sheets of guidance going to every hospital and care home in the country on what has to be reported and in what form. This is the kind of bureaucratic madness that can follow half-thought-out bits of legislation.

Baroness Murphy: I support the group of amendments. Getting service users and carers involved in the day-to-day practice of what the commission does is so crucial. To take on board their expertise—we now talk about expert patients, because they very often know more about their conditions than we do as professionals—their experience and how they are treated in services is crucial to being involved on a day-to-day basis in how the commission works.

The noble Lord, Lord Patel, and the noble Baroness, Lady Meacher, have clearly outlined what dramatic changes we have seen in mental health services and in social services, as the noble Baroness, Lady Barker, said, from a much more adventurous involvement than is envisaged at the moment in the Bill. We have to get something more ambitious in it, to make sure that the new commission really will be at the cutting edge and will truly involve people, because that makes a step change in the way in which services develop and respond to service users. That is what it is all about.

I am not sure about the point made by the noble Lord, Lord Lipsey. I envisage lots of future episodes of “Casualty” with people filling in forms and sending them off to one commission or another; I hope not. There will never be a time when all those comments get accepted and remarked on as perhaps they should. The involvement in the work of the commission is utterly crucial, and is possibly more crucial than the first group of amendments, although they, too, are important. This will give service users what they need.

Lord Campbell-Savours: I do not come to this debate as a professional in this area; my knowledge is very limited. My experience outside the institution of Parliament is in engineering, and I am more used to dealing with milling machines, capstan lathes, plating plants, pressings and trade exhibitions. I come almost as a virgin to this debate. I support the thrust of the amendment proposed by the noble Baroness, Lady Barker, but I want to speak to Amendment No. 104, proposed by the noble Baroness, Lady Meacher, which to me is particularly significant. It says:

(1) Persons authorised by the Commission to enter and inspect any premises shall include lay inspectors. (2) In this section "lay inspectors" means persons not trained in the profession or employed in the service being inspected”.

I am one of those people. I want to explain why I think that is very important.

Prior to placing my mother in a nursing home, I visited 19 homes, some of which, I presume, had been the subject of inspections, and which were absolutely appalling. Half of them, to put it bluntly, stank of urine when I went into them. Those were homes which, under the current inspection regime, somehow cleared the hurdle of acceptability. There was one

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particular home, not very far from this institution of Parliament, in which I would not have kept an animal. The fees were over £1,000 per week. There were more than 30 residents in the home. That is the real world that goes on outside, and when people like me, who have very little knowledge in these sorts of areas, are confronted with a decision to place someone in a home, to put it bluntly, we wonder what the hell is going wrong and how homes such as that one manage to clear the hurdle. If it is that the professionals are prepared to put up with that standard of care, it is about time that lay persons had some rights in these issues and had a right to influence events.

I positively endorse the amendment proposed by the noble Baroness, Lady Meacher. In my view, that amendment would probably make a major contribution to dealing with the problems with which I was confronted when visiting those homes. If I were a lay inspector, and I found homes stinking of urine, as I did—Monday mornings can be difficult in homes—and if during the balance of a week you are confronted by the smell of urine when you go into a home, I would want action. To this day I do not understand how that is allowed to go on.

4.45 pm

I toured the rooms in one home, which, presumably, had cleared its inspections under the current regime. Under the diluted arrangements that we are going to introduce, I cannot imagine how bad it will be. As I went around that home, clients were lying semi-naked on beds with the doors open, and I could see in as I passed those rooms. The rooms were dilapidated and undecorated. The beds were iron framed, which reminded me of when I was away at school in the 1950s. For that kind of conditions, there were huge fees—some were far in excess of £1,000 per week—to which I shall turn in a later amendment. However, I should like to say that the home I have found for my mother is excellent.

The homes to which I am referring are finding a clientele. I wonder what families are placing their loved ones in these homes. How often are people visiting these homes? Are they simply dumping their families and oblivious to the fact that conditions are bad because they have never regularly inspected them themselves? It is not a question of the people going into these homes having rights, because very often they are beyond the capability of understanding the conditions in which they have been placed. This whole area needs a major shake-up. Based on my experience, I hope that this Bill gives us the opportunity to bring about the changes in which I very strongly believe.

Earl Howe: After those extremely powerful speeches, there is little for me to add, except to say that Amendment No. 15, to which my name is attached, is an attempt to beef up Clause 2(3) which, as it stands, is rather feeble. I hope that, if nothing else, the Government will take away the need to strengthen that part of the clause. The amendment refers to engaging,



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I like the word “engage”. If I were to be honest, I should also like to see the word “involve” included, which is why I like a great deal of what Amendment No. 27 is trying to do, even though my name is not attached to it.

There is no explicit reference to service users, families and carers in the Bill. There should be. The essence of Amendment No. 27 is excellent. I very much like the mention of special reviews, as the noble Baroness described. She also rightly mentioned the relevance of her amendment to detained patients in particular. Where I depart from the wording of it slightly is that it is a little vague in the wording of new subsection (1)(e). It is perhaps not as clear as it might be in defining the duty that the CQC will be expected to fulfil. But, with that slight reservation, I commend it to the Minister.

Lord Darzi of Denham: The amendments in this group all seek to establish a more general duty for the commission to involve people in its work. We discussed the proposal for the commission to have a children and adult rights director—touched on in Amendment No. 108—in our last session, so I will not repeat the arguments I made on that specific element. I have already referred today to the requirements set out in Clause 2 for the commission to have regard to the views expressed by and on behalf of members of the public, including patients and service users and those who represent them, such as LINks. I would expect the commission to cover these matters in its annual reports on how it has exercised its functions under Clause 79. But this is an area I will look at again when reviewing involvement as I undertook to do in the last group of amendments.

I hope that the noble Baroness, Lady Barker, would therefore feel able to withdraw Amendment No. 15, which seeks to ensure that the commission will have mechanisms and channels for engaging with people who use health and adult social care services, and not move Amendment No. 108, which would require the commission to report on what it had done in this regard in its annual reports.

Amendment No. 27 was tabled by the noble Baroness, Lady Meacher, and is supported by my noble friend Lord Patel. My noble friend Lord Campbell-Savours, too, led a powerful debate on the proposed new clause, which sets out in more detail how service users and the public should be involved. The proposed new clause proposes specific requirements for the commission to involve lay persons in its inspections and in special reviews. It also proposes a general requirement for the commission to provide information and to consult on how it exercises its functions, or to involve it in other ways.

Amendment No. 104, which the noble Baroness, Lady Meacher, also tabled, specifically provides that the people authorised to carry out inspections will include lay people. The Bill already allows for lay involvement in inspections, and I fully expect the commission to use lay inspectors either in inspections that are carried out for registration purposes or in other site visits associated with service reviews. In this regard, the provisions in the Bill reflect existing

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legislation, under which the Commission for Social Care Inspection has developed its Experts by Experience scheme. The Healthcare Commission also uses lay representation in its visits. Similarly, the Mental Health Act Commission, as eloquently described by my noble friend Lord Patel, includes lay people with significant direct experience of mental health services, as well as professionals such as lawyers, doctors, nurses, social workers, psychologists and other specialists, in the 100 commissioners who carry out the commission’s visiting programmes. I certainly expect the Care Quality Commission to follow the excellent examples set by the current bodies in this regard.

However, my understanding is that the current bodies do not support routinely involving lay representatives in every visit that they undertake. I am sure noble Lords will appreciate that there might be circumstances in which it might not be appropriate to do so. Indeed, we would not want the commission to have to wait until it could secure the services of a lay inspector where it needed to carry out an urgent inspection. It is therefore right that the commission can involve lay people in inspections as it deems appropriate.

Baroness Meacher: Amendment No. 104 does not require lay people to be involved in every inspection, although I think the Minister is indicating that it does. It simply implies that they should be part of the group of inspectors so that they can be selected as appropriate.

Lord Darzi of Denham: I am grateful for the noble Baroness’s clarification of the amendment.

We have also sought to ensure that the commission is required to approach its task as openly and transparently as possible. The Bill already requires the commission to consult and to provide information on how it will approach particular functions, including guidance on how it will determine compliance with registration requirements; a code of practice on how it will handle confidential information; its plans for charging fees; its plans for carrying out special reviews, other studies and research; and guidance on how it will approach using its enforcement powers.

In addition, the commission will be required to make available on the register information, reports of any inspections that it carries out for registration purposes, and details of what enforcement action it has taken. There is therefore already ample provision for patients, service users and carers to access information on the commission’s key functions and to influence them.

Lord Campbell-Savours: Why cannot a lay person inspect every care home? Why cannot we make it mandatory? Why cannot we have pools of people who are available to carry out inspections in local authority areas and who are drawn from the local community? Enough people out there have an interest in doing so. I cannot see why there should be any discretion. Surely we could create arrangements whereby it was mandatory.


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