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If we break again for a Division in the Chamber, the Minister will have another opportunity to check up on the exact cost of this reorganisation, because despite having seen various documents I am still not clear on precisely how much it is going to cost. The three bodies will have to disband the buildings they occupy, whether they lease or rent them, and be set up somewhere else. Staff will have to be paid off and new staff taken on. I would like to know what the costs are for doing all that, and perhaps be told, for example, how many midwives that money would pay for if it were used on them instead.

The three bodies to be merged by the Bill have been in existence for only three years, which is a pretty short time. They have just settled down nicely and presumably are content with their offices and organisational structures. They probably have the right kettles to make tea, which in my experience is one of the most important things. The first consideration in a reorganisation is where you will be able to make the tea and eat your sandwiches. I hope that they have a clear idea of what they are doing. In my short time with this brief I have been impressed by the work of the Health Services Commission, CSCI and the Mental Health Act Commission, but instead of a merger being allowed to evolve, along comes a totally unnecessary reorganisation imposed from above. I have to say that it feels a bit like a job creation scheme for the Civil Service. I have enormous respect for the civil servants in the Department of Health but, as we plough through this Bill, I am beginning to wonder whether it is not just something to keep everyone occupied.

I am going to speak from my personal professional experience, although no one could match the eminence of noble Lords in this House. I worked in the health service for 33 years and I was there at the coal-face. My husband was a hospital doctor working as a neuroradiologist, so my family never understood what he was talking about. But I think they understood what I did; indeed, they used to call me “Barefoot Doc” because I was in general practice, community services and family planning. During that time I was also a chair of social services for my borough, so I saw things from the lowest point of view possible.

One of the problems I encountered during my last 20 years in the health service was implementing reorganisations. It took over almost two-thirds of my professional life. At first I managed women’s services, and then after a reorganisation I managed community health services, but they were reorganised into oblivion. I am still hoping that polyclinics will encourage a resurgence of what we used to call community health services. However, and this applies equally to the commissions as well as to government reorganisation, each new chief executive that appeared had to do his own little reorganisation. They would tinker with the structure, and sometimes it seemed to be something

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just to put on their CVs before they moved on to new positions. In my experience, reorganisation is the absolute curse of the health service.

I hope that the noble Lord, Lipsey, will help me with this since I am supporting his amendment. We had permanently displayed in our offices and clinics the Latin tag attributed to Gaius Petronius, whoever he was, which translates into English as:

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Do civil servants or Ministers have any idea how damaging reorganisations can be, especially after such a short time—three years, barely time for them to know precisely what they are doing? Why do we not merely insist that the three existing commissions work from the same building? In my experience, I find that people who work from the same building, who share the same tea-making facilities and go to the same cafes at lunchtime, share ideas and get together much better. It certainly happened at local level with health and social services workers, so why not with the commission? Why oh why cannot it evolve instead of breaking up three very efficient organisations? I have listened very carefully to what Sir Ian Kennedy and Dame Denise Platt have said, and I respect those two individuals immensely.

I repeat that this reorganisation will overshadow social care and mental health care in this country, because the commission will have to concentrate on the health service. The Government are taking a step too far, far too quickly, in an attempt to look busy. I am very happy to support the amendments in an attempt to retain some of the expertise in the commissions that will have to be disbanded.

Baroness Masham of Ilton: I shall be very brief. I must disagree with my noble friend Lord Low about the priority of hospital-acquired infections. With the horrific deaths of people going in to hospital for routine surgery and dying from C. difficile or MRSA, surely there is no point having social care if a patient is dead. That can happen in care homes as well. Infection control must be a top priority. It seems to me that there will be in-fighting within the CQC, so the amendments are very important.

Lord Patel of Bradford: Where does one start? So many important things have been said. I start by congratulating the noble Baroness, Lady Young, on being chosen by the Secretary of State as the preferred candidate to be the shadow chair. I know that the Committee had a long debate yesterday about concerns and anxieties about the timing of this appointment, and I sat and listened very carefully to all those anxieties and concerns. Obviously, I cannot speak for the Healthcare Commission or the Commission for Social Care Inspection, although I was on the board of the Healthcare Commission for several years, but I can speak for all the staff, commissioners and second-opinion appointed doctors—in total, about 300 people—in the Mental Health Act Commission.

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We are where we are with the Bill. Whether or not it is a good idea to merge the three organisations, we have come a huge way; we have travelled a long journey. My anxiety is that I am going to lose a number of specialist staff unless we get on with the show. It is really important that the shadow chair shows some leadership by saying where we are going and how we are going to get there. I understand the anxieties—I have raised them myself—but the next three to six months are crucial in keeping the show on the road for the Mental Health Act Commission and for detained patients, ensuring that all the expertise that we have remains. There is a worry that that will not happen if we continue to raise concerns that might destroy people’s confidence in remaining where they are.

Baroness Barker: I take the noble Lord’s point that we are where we are. Where we are at the moment is that we have a Bill in front of Parliament that a number of noble Lords have expressed fundamental anxiety about. They are not being flippant. The Bill is not through Parliament yet, and may not pass. What is the risk to the Mental Health Act Commission of losing staff in the event that the Bill does not pass and the commission continues in existence? I do not understand why that should be.

Lord Patel of Bradford: Staff have got the message from all quarters that the Bill is passing through Parliament.

Baroness Barker: Does the Minister accept that it is possible to explain to them that we have a parliamentary procedure and that such an arrogant assumption on the part of the Government is misplaced?

Lord Patel of Bradford: It is nice of the noble Baroness to call me a Minister, but I am certainly not there. The reality is that many good staff in the Healthcare Commission, CSCI and the Mental Health Act Commission have been jumping ship because of anxiety about what is going to happen. Many are unhappy about it. They see 31 March next year as a deadline, and there are all sorts of concerns. I am not arguing about whether they are right or wrong, but that is the reality.

I come back to the commission and where it stands. The staff have been keen to get some leadership into position and to see what the future holds. I come back to the important issue expressed so eloquently by the noble Baroness, Lady Murphy, that we have always had a statutory body that has looked after the concerns of detained patients. I, more than anyone, am concerned about that. I joined the commission as a visiting commissioner in 1995. Every week I visited high security hospitals and local hospitals and saw lots of abuses of the Mental Health Act on a day-to-day-basis. I was frustrated by what I saw and by what I could not do. I became a lead commissioner and took teams of commissioners into hospitals. We dealt with lots of issues but were very concerned about the fact that our powers were limited.

I became vice-chairman and then, when I became chairman, I reorganised the whole commission because I thought that we were not tackling those

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fundamental issues. A team of us would go into a hospital, find a load of issues that were wrong and then, a year later, because we had limited resources, we would go back and find that more than half, maybe three-quarters, of the issues we had raised were still there; nothing had been done about them. Service users and patients constantly told us, “You’re nice people, you do some really good things, but you’re useless when it comes to my kind because you haven’t dealt with this. I’ve been abused and you waited a year to come back”, even though we had followed it through, because people did not go in.

I made changes at the commission. Now individuals go in regularly and frequently. We have teams and support networks that cater for their comradeship, and people can go in at any time. They are consistent in their visiting. If they come across an issue they will deal with it with the ward manager, the chief executive or the area commissioner. They can even go back in the next day because of the flexibility we have created. It is important that we have created that new structure.

In that body of commissioners there are 107 people. You can pick up the phone and ask about any ward in the country that has detained patients, and someone in that organisation will tell you about it; they will tell you what is wrong and what is right with it and what is happening. I do not want to lose that expertise.

I am also concerned—and this has come from our service user reference panel, of all people; the people we were talking about yesterday—that our role is limited. When commissioners go into hospitals, they interview detained patients in private. That is important, because a lot of our information about what happens to people comes from those who do not want to see us. We find out so much.

We are also looking at how the Mental Health Act is monitored. That is what we are there for. We have to walk past people who may be being treated appallingly but under the law we have to turn a blind eye because it is nothing to do with us. It is none of our business, and we have been told that many times by esteemed lawyers and academics. So for us this organisation is beneficial in being able to look at the whole pathway of patients who are deprived of their liberty but are not detained under the Act. Sanctions and enforcement measures will be available to enable us to deal with these issues. We shall be able to understand why patients are in these places and question what happens after they leave. That whole pathway is very important. I do not want to recreate those silos in a new organisation that is supposed to do away with them. I struggle in respect of Amendment No. 25 in terms of having silos, particularly in social and healthcare, as these bodies have been designed to have a seamless health and social care policy.

I am sympathetic to Amendment No. 93 as it tackles the specialist nature of monitoring the Mental Health Act. This is not about mental health per se. I take on board the point made by the noble Baroness, Lady Howarth, about people with learning disabilities and others also requiring a pathway, a journey into care and wrap-around services. The responsibility under

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Section 120 of the Mental Health Act to review the powers and duties of that Act is to be moved lock, stock and barrel to this new organisation. It will have a special legal remit to undertake that. I am reassured by Ministers and officials—and by the fact that this duty will be transferred lock, stock and barrel to the new organisation—that visiting and interviewing detained patients will continue on a fairly frequent basis. That is important. However, there needs to be a mechanism in this organisation—Amendment No. 93 would go some way to achieve this—to monitor the powers and duties of the Mental Health Act. That is important. The day-to-day work of the Mental Health Act Commission is to safeguard the interests of detained patients. Even if there is a crisis, that duty will never be relinquished. We will still safeguard the interests of detained patients, interview them and ensure that they receive appropriate care and treatment. I hate to mention MRSA or C. difficile, but if mental health is the Cinderella of health services, they have the potential to be the two ugly sisters that alter the focus as regards what should happen to a small group of patients. I support the concept of Amendment No. 93—I ask my noble friend to ensure that the interests of these patients are safeguarded—but in general I do not support Amendment No. 25.

Baroness Barker: I listened carefully to what the noble Lord said. I understand entirely his point about the duties of his commission being transferred to the new commission. However, can he explain or share with me the basis of his confidence that the expertise and resources of the Mental Health Act Commission will be transferred to the new commission?

Lord Patel of Bradford: I am anxious that we have somebody in place with whom we can take forward the discussions that we have had with officials over the last year and a half to two years. We should bear in mind that when the Mental Health Act Commission was supposed to be transferred to the Healthcare Commission three years ago, we had discussions to try to safeguard this group of people and their expertise. We have had meeting after meeting on that and I have been assured by officials and Ministers that they value that expertise. What I need now is reassurance on that point from the new chief executive. I need to discuss this matter with the relevant people once they are appointed.

Baroness Barker: Does the noble Lord concede that all members of the committee need that reassurance? Will he share with us the contents of the documents on which he bases his reassurance?

Lord Patel of Bradford: They are not documents but discussions I have held as a chair of the Mental Health Act Commission. As such, my responsibility is to ensure that we carry on delivering the best possible service to detained patients and to retain the staff and commissioners who can deliver such a service. They are clearly saying to me, “We need leadership and forward planning and we need to be confident that we have a role in future”. However, at this moment in time that is not the case.

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7.15 pm

Lord Walton of Detchant: In the interests of time, I shall be extremely brief. I wholly accept the principle, having accused the Government on more than one occasion of establishing an intolerable quangocracy in the field of health, that a reduction in the number of quangos is important. But if the Government have examined, as I hope that they have, the enormous burden of work and responsibility carried by the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission over the past few years, how can they possibly expect the Care Quality Commission to fulfil all three functions without the establishment of three individual subcommittees or sub-commissions to look at each sector independently, with the parent commission acting in a co-ordinating role? I very much hope that the Minister will be able to say that that is a principle that the Government will accept. If they accept it, why not put it in the Bill?

Lord Low of Dalston: That contribution does not leave much more to be said and it had the great merit of being a good deal more succinct than the contributions of some of the rest of us. Perhaps I may be permitted to respond to the noble Baroness, Lady Masham, and make a couple of other points.

Baroness Thornton: Would it be appropriate for me first to respond on behalf of the Government? Time is moving on.

Noble Lords have eloquently expressed their concerns that social care or mental health may be marginalised within the new body. That theme has run throughout the discussions on the Bill. I assure noble Lords, as did my noble friend the Minister did at Second Reading and on several other occasions, that we have set the new Care Quality Commission’s functions squarely within the legislation. We have continuously made it clear in both Houses that the social care and mental health functions must have parity in the new commission. The integration of the three current commissions will not mean that social care or mental health are overwhelmed by health within the new body. These different and vital roles will be reflected on the board and in everything that the commission does. When the noble Lord, Lord Low, expressed his anxiety about the board some time ago—in fact, two Divisions ago—he built a case about lone voices that those reassurances have not yet satisfied. So again I say to him and to the Committee that board members will have a collective responsibility for the decisions made by the board, whose role is to ensure that the organisation delivers the business plan, as agreed. They will be held accountable for this and they will reflect the three different strands of the commission.

In relation to the comments on creating separate sub-commissions, we are bringing health, social care and mental health regulation together into a single organisation creating an integrated regulator. I feel slightly that one can never please the noble Baroness, Lady Tonge. The Liberal Democrats supported such a proposal three years ago, so I would have thought that she would be congratulating the Government on at

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long last seeing the light. As the noble Baroness, Lady Meacher, said, the proposal in the amendment carries a very great risk of creating “silos” within the organisation even before it gets to first base. This is what we must seek to avoid. The only way of preventing competition between the different elements is to create a single organisation with overall responsibility for the regulation of health, adult social care and mental health.

Baroness Barker: The noble Baroness will be aware that on the basis of the recruitment material publicly available so far and statements made by Ministers in another place, in the world of social care there is at the moment a deep sense that the likelihood of representatives of social care figuring among the senior management of the CQC is extremely low. Could she address that in her response?

Baroness Thornton: I do not think that there is any evidence to suggest that. Indeed, in her exchange with my noble friend Lord Patel, the noble Baroness suggested that, because he had been given assurances verbally, they would not carry any weight. That is unfair and not quite how we normally conduct our exchanges. I hope that she does not mind me saying that. However, I agree with her about the advertisements, and indeed we discussed the issue yesterday. My noble friend Lord Darzi explained that an apology had been made, the readvertisement had been launched, and the whole thing had been put on a different track. That assurance has been given by my noble friend and I hope that we can now move on to the discussion we are holding this evening.

The commission will, of course, need expertise in particular areas. It may decide to set up committees with responsibility for specific matters. We envisage that much of this expertise will transfer from the current commissions, and the new body will build on this. The current commissions have developed excellent ways of working. Noble Lords have mentioned that on many occasions, and it is indeed the case. Engaging with those who use services and employing improved methodologies will inform and enhance the work of the new commission. Moreover, as my noble friend Lord Darzi said at Second Reading, we attach great importance to the role currently played by the Mental Health Act Commission. We will work with all three commissions to ensure that the body is effective at protecting the rights of all vulnerable groups under its remit. This will include those detained under the Mental Health Act, and we will stress how important it is that the skills and expertise required to carry out the Mental Health Act’s statutory functions, including visiting arrangements, are retained in the new body.

We have made provision for the commission to set up the committees and sub-committees that it feels are necessary for the effective discharge of these functions. However, we believe it is important that the commission, as an independent body, should be allowed to use these provisions flexibly rather than have imposed on it structures that it may not find useful. Here, I refer to our earlier discussion when noble Lords were concerned about the independence of the commission. This is an important element of its independence. It will need to work out what kind of bodies it should set up internally.

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I hope that I have been able to reassure noble Lords that we take this matter extremely seriously. The provisions in the Bill are intended to give the new body the flexibility and independence to establish itself in a way that allows it to carry out its functions most effectively. I think that the commission would be wise to look at the proposals set out in the amendment tabled by the noble Baroness, Lady Meacher. They seem to be a very sensible way forward in dealing with the mental health provisions that she talked about so eloquently. With that, I hope that Amendment No. 25 will be withdrawn.

Lord Lipsey: Briefly, although I can see where it comes from, I do not believe that the silo argument holds water. That is because we have a silo buster built in here in the form of the commission itself. It will be its job to integrate the work of its sub-committees, as happens on the board of almost every organisation of which one has had experience.

Although I give some weight to the staff insecurity argument, the obvious debating point is that if the Bill were to be withdrawn tomorrow, that would be the end of staff insecurity. The Bill is causing the insecurity and making people think about leaving, although in my experience fewer people actually leave than those who talk about doing so.

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