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Amendment No. 66B would enable people appointed under Clause 37 to act as the registered service provider for a specified period. Clearly, as long as the business remains operational, it will be important that services are overseen by someone with the appropriate skills to ensure that safety and quality requirements are adhered to. Clause 37 already allows for the person who takes control of the business to be required to appoint a suitable manager to ensure that this happens. However, it would not be appropriate to expect someone who is stepping in to arrange the financial wind-down of the business to accept responsibility for the safety and quality of service it provides, even on a temporary basis. As I have already said, in the case of individual voluntary arrangements, the insolvency practitioner does not assume control of the business anyway. Nor would it be appropriate for the official receiver, as an officer of the court and a member of the Insolvency Service, who would be the trustee or liquidator of last resort in bankruptcy and court winding-up cases, to be asked to register.

I hope that I have been able to explain how the Bill deals with these issues and that the noble Baroness will feel able to withdraw the amendment.

Baroness Barker: That answer was helpful in parts. If a small service provider has to go into an individual voluntary arrangement, it is then in serious financial difficulties. I suspect that the Minister is as aware as I am of the very strong temptation for small businesses in that situation to attempt to try to trade their way out. A reason for proposing this amendment is that some people who buy this care will do so on their own behalf, so it is important that they are protected.

I note what the Minister says about liquidators, but I think that the Government need to spend a bit more time thinking through the full implications for a very small business in this situation. There is a potential for a disruption to services that has not been thought about.

I shall take away what the Minister said and look with some care at the consultation later on this year. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 66B not moved.]

Clause 37 agreed to.



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Clause 38 [Death of registered person]:

Earl Howe moved Amendment No. 67:

(i) a sole person has been registered under this Chapter as a service provider in respect of a regulated activity, and(ii) the person has died;”

The noble Earl said: This is no more than a simple drafting matter. Clause 38(1)(a) says that regulations may,

It is clear what is meant, but I wonder whether the syntax and sentence construction could not be made a little better. If we talk about a situation where the only person registered under this chapter as a service provider has died, it rather suggests that the provision might apply only where one person in the whole country was registered as a service provider and that person has died; but we do not mean that. In an effort to be helpful, I have proposed an alternative form of words, which I hope that the Minister will consider. I beg to move.

Baroness Thornton: Clause 38 deals with what happens when somebody who is registered as a service provider dies. This mirrors a requirement that currently applies under Section 35 of the Care Standards Act 2000. In these situations, it will clearly be important that there is some continuous service provision and, equally, that services are overseen by somebody with the appropriate skills to ensure that safety and quality requirements are adhered to. This will be particularly important where the service provider is also managing the services.

The clause therefore allows for regulations to set out the procedure that will apply for notifying the commission of the death of a service provider. This would obviously be a sensitive time for those involved, and it will be important that the commission is notified within a reasonable timescale and that there is clarity about the procedure for doing so. I had some sympathy with the noble Earl when he read out that paragraph because, when I read it, I agreed. However, the lawyers tell that this must be so, and this is how it must be worded.

As for the current legislation, Clause 38(1)(a) makes it clear that regulations may provide suitable arrangements for those cases where there is only one person registered as a service provider in respect of a specific regulated activity and that person has died. Amendment No. 67 probes the wording and meaning of this provision. Drawing on the fact that under the Interpretation Act 1978 a “person” includes a body of persons corporate and unincorporated—that is, companies and government departments—the amendment seeks to clarify that this provision can, and should only, apply to natural people; in other words, “a person”.

I hope that I can reassure Members of the Committee that the meaning is already clear from the context, and that these provisions, as currently

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worded, are already well understood by those currently registered with the Healthcare Commission and CSCI under the Care Standards Act. I hope that Members of the Committee will therefore agree that we need not redraft these provisions and that the amendment can safely be withdrawn.

Baroness Cumberlege: I support my noble friend on this. As a classical scholar, he is of course quite right. Perhaps the Minister may take a little courage and challenge the lawyers, because that argument does not wear with me.

Baroness Thornton: I have a lot of sympathy with the noble Baroness; indeed, that was what I was doing over my shoulder. I will continue to do so on this one.

Earl Howe: I am grateful to my noble friend for stiffening my sinews on this; I was going to concede very meekly to the Minister. If she undertakes to investigate this a little further, I shall be extremely pleased, but, for now, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 38 agreed to.

Clauses 39 and 40 agreed to.

Clause 41 [Standards set by Secretary of State]:

[Amendments Nos. 68 to 71 not moved.]

Clause 41 agreed to.

[Amendment No. 72 not moved.]

Clause 42 [Periodic reviews]:

[Amendment No. 73 not moved.]

5 pm

Baroness Tonge moved Amendment No. 74:

The noble Baroness said: I make no apology for returning to health promotion. I took care to read some of last week’s debate on the Bill, particularly the speech of the noble Baroness, Lady Cumberlege, in which she said that she always found health promotion rather boring. I beg to differ—I do not find it boring in the least. In my early years as a general practitioner, I used to think that if you could make a patient happy, they were usually healthy or they thought that they were. It was an important thing to do. One of the reasons I went into politics was that I decided that patients were usually unhappy because of circumstances such as terrible housing, poor education or too many or too few children. They were not matters which concerned the health service.

The downside—if I dare utter it in this Building—of having a national health service free at the point of delivery is that a high proportion of patients somehow devolve their own healthcare to the National Health Service. That was certainly the case with an awful lot of patients whom I saw. Their healthcare was no longer any of their concern. What they did to their bodies, how they abused them or how they lived did not matter, because the health service would put it right. We have to recognise that some

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people do not give a fig, because they know, think or say, “It’s my right to have it put right if I abuse myself in this way”.

Another factor that prevents good health promotion is confusion of messages. It is quite extraordinary how much the press and the media will grab any little thing. A medical researcher may come up with something in some obscure journal—for example, if we all drink lots of red wine, we will all be extremely healthy, because that is what happens in France. That is a crude example, but there are numerous other such examples of silly, small research projects being publicised in this way. Having been a junior doctor, I know of people who are desperate to get into the press, to get their name in print and get a paper written. The newspapers will take it up and, as a consequence, the general public become incredibly confused.

I was a community services manager in Ealing a long time ago. One of my clinics was in Southall, an area with a large Asian community and, consequently, high levels of diabetes and cardiovascular disease. At one end of the clinic, dentists would tell mothers and children that they must end their meals with a nice, bland piece of cheese because the acid from fruit would rot the enamel of their teeth. At the other end of the clinic, the health visitors were waging a huge campaign to try to stop the population of Southall eating animal fats, cheese, ghee and so on because that was terribly bad for their health and would give them heart attacks.

I promise the Committee that that sort of thing goes on in one clinic. I suspect that it still goes on in some GP surgeries. Sadly, over the past 10 years, community services and community clinics have tended to disappear because the targets for the primary care trusts have been all about hospital care and GP care. That has shown some benefits because the promotion of those targets has seen, as the noble Baroness, Lady Cumberlege, said last week, a reduction in deaths from heart disease; a reduction in deaths from many cancers; and much better investigation and treatment of many cancers. A lot of good work is going on because of those targets and because of the work being carried out in general practices and in hospitals.

The work that used to be done primarily by community workers, health visitors, district nurses and school nurses was crucial in young people's lives: they were told what they should be doing, what they should be eating, when they should start having sex and so on. Over recent years, services such as family planning and sexual health clinics have been reduced. We have not seen much movement in teenage pregnancy rates, but we have seen a rise in HIV rates, a rise in sexually transmitted diseases up and down the country and, of course, a rise in obesity because no one is receiving the sort of advice which health visitors and school nurses used to give routinely to mothers, babies and small children. Alcoholism is rampant. I do not know where one lays the blame for that, but I suspect that advertising and manufacturers’ profits have much to do with the rise in alcoholism.



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There is a huge job to do and the need to promote a particular lifestyle may be different in each community. I know Southall well and I know that we had to work on particular problems there. That is why this should be done at PCT level. We feel that, in future, the Care Quality Commission should ensure that the primary care trusts do not neglect all those services for health promotion and health prevention which are so essential. I beg to move.

Baroness Thornton: I completely agree with the noble Baroness, particularly on the need for clarity in health campaigns and what a huge job there is to do. In carrying out reviews of the provision of healthcare, by and on behalf of PCTs, the commission must consider PCTs’ health promotion activities. That chimes in exactly with what the noble Baroness was saying. For example, if a PCT is running public health campaigns on screening programmes, the commission should be able to assess how the PCT activity has contributed to it meeting that particular need in its local population.

That is why Clause 92 clarifies that the provision of healthcare includes the promotion and protection of public health and the provision of services connected with the provision of healthcare, except in relation to the commission’s registration functions under Chapter 2. For the purposes of Clause 42, therefore, healthcare absolutely includes health promotion, and I hope this addresses the intention behind Amendment No. 74.

Amendments Nos. 99 and 100 seek to require the commission to keep the Secretary of State informed about the improvement of NHS care and adult social services as well as provision. Clause 49 is very broad. It is aimed at ensuring that the Care Quality Commission can provide any information and advice to the Secretary of State. It is vital that there are good lines of communication between the commission and the Secretary of State. The commission will build up knowledge and expertise while carrying out its functions which it may then draw on to provide advice to the Secretary of State. The clause will enable the commission to advise the Secretary of State on the improvement of statutory healthcare and adult social services. Such advice will be vital to the Secretary of State in developing the appropriate requirements to ensure that services are safe, of good quality and continue to improve.

As Clause 2 already requires the commission to perform its functions for the general purpose of encouraging improvement, it will need to advise the Secretary of State of relevant matters—that is, the improvement of services—to properly fulfil this role. I therefore believe that the Bill makes adequate provision to ensure that periodic reviews of PCTs and those acting on their behalf cover health promotion. Under Clause 49, the commission will be able to advise the Secretary of State about improvements as well as the provision of NHS care and adult social services. So I would ask the noble Baroness to withdraw her amendment.

Baroness Tonge: I thank the Minister for that response, which was very encouraging. I do not think that there is any more to be said. I am delighted that

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she agrees with me and that we now have it on record that Clause 49 is intended to include—I think she said—health promotion. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Barker moved Amendment No. 74A:

“( ) demonstrate how this judgement will contribute to the Audit Commission’s assessment of local areas,”

The noble Baroness said: In moving Amendment No. 74A, I shall speak also to Amendments Nos. 75A and 75B. I wish to point out something that I have mentioned already on a couple of occasions. No material circulated for the recruitment of the chair of the Care Quality Commission made any mention of comprehensive area assessments, nor did they mention local government. A key driver for the commissioning and provision of social care—although not for its assessment—is the comprehensive area assessment for all English local authorities, which is audited by the Audit Commission. The comprehensive area assessment requires local authorities to state how they will address and improve the social and health outcomes of the population and to make an assessment of the prospects for improvement of health and social care. It monitors closely how well local organisations work together in order to achieve those outcomes.

The comprehensive area assessment is key to social care—its planning, assessment and monitoring. Its absence from primary legislation, as with so much of this Bill, appears to be downgrading key parts of social care. Therefore, these three amendments seek to restore that emphasis in primary legislation by requiring local organisations to show how their work will contribute to the comprehensive area assessment. Much of the work that CSCI does is done in tandem with the Audit Commission. In social care those two bodies look at many of the things which affect people’s lives. In a way, this is a redress of that.

The other matter which these amendments seek to probe is what exactly is intended by the word “periodic”. Comprehensive area assessments are annual; the word “periodic”, when last I looked in the dictionary, is ill defined. It does not state what the period is going to be. What are the periods to which “periodic” refers? I beg to move.

5.15 pm

Baroness Thornton: I am grateful for the opportunity to explain how the commission’s reviews will contribute to the new comprehensive area assessments of local areas that will be introduced from April next year. As described by the noble Baroness, the CAA forms part of the new local government performance framework, set out in the Government’s 2006 local government White Paper, Strong and Prosperous Communities. It will be an important new step in producing integrated assessments of local services against common goals. The assessment will be carried out against the outcomes of local area agreements and a national set of 200 cross-government indicators. I agree with the

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noble Baroness that it is essential that the commission’s reviews feed into that assessment. She is correct to say that the work of the CAA is very important—and in her comment on the fact that CSCI’s work is already integrated into that, which gives us an indication of how that is likely to continue.

As my honourable friend the Minister clarified in another place when debating this Bill, where the indicators used in reviews under Clause 42 relate to local authorities working alone or in partnership with PCTs, other NHS bodies or other local service providers, they will form part of the single set of national indicators to be used in comprehensive area assessments. The commission will work closely with the Audit Commission to ensure that that happens. The national indicator set was announced in October as part of the Comprehensive Spending Review; the details of the indicators are being published by the Department for Communities and Local Government. There are 31 indicators covering health and well-being and adult social care which appear in the national indicator set and the NHS vital signs to support partnership working.

The Government have also commissioned the seven current inspectorates with a role in local authority assessment to work together to develop and test a methodology for carrying out CAAs, and they carried out a joint consultation on their proposals in November last year. This methodology has been trialled in four local areas in order to work through in more detail how the CAA will need to operate on the ground. The learning from this process will be reflected in a second joint consultation this summer, which will set out more detailed methodologies for the CAA, along with more structured piloting in a further 10 authorities. The first joint CAA judgments are then expected to be published by the relevant inspectorates, which will include the Care Quality Commission, in the autumn of 2009. This will be a transition year, with full implementation the following year.

I hope that the noble Baroness will be reassured from this that arrangements are being taken forward to ensure the Care Quality Commission’s assessments will be fully integrated into the CAA process and that she will therefore agree to withdraw the amendment.

Under current legislation, the Healthcare Commission and Commission for Social Care Inspection are required to review NHS bodies and local authorities on an annual basis. We have altered this to allow more flexibility, precisely because we believe that the commission is best placed to decide on the frequency of periodic reviews and the periods they cover. Of course, the commission will also want to take into account the timing of comprehensive area assessments in making that decision.

Baroness Barker: I thank the Minister for that reply. As with so many of her answers, although I realise that they are intended to be helpful, it sits against the backdrop of the Bill as it is. Anybody looking at Clause 42 sees a range of health providers in there and one mention of adult social services. The reason for tabling these amendments was, again, to try to rebalance the legislation towards social care. I am afraid that that must be done. It is vital that the CQC carries on the good work of CSCI with the

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Audit Commission, which has brought about a new level of measurement and assessment of social care services. That risks being overshadowed if it is not explicit in the legislation, which it is not.

I take the point about allowing a degree of flexibility, but were the CQC not to be involved on an annual basis with comprehensive area assessments then the resulting documents would be somewhat lacking. However, I have listened to what the Minister has to say and, on that basis, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Earl Howe moved Amendment No. 75:


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