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Health and Social Care Bill

My Lords, I am always happy to follow the noble Lord. Many of the points he made I wished to address in some ways. Before starting, let me declare my interests as president of the Abbeyfield Society, a charity with several hundred homes across the country providing care and special care for elderly people; as a non-executive director of BUPA; and as a consultant in an executive search firm involved in many of these areas—although, unfortunately, not in the search to find the chair of the Care Quality Commission. If we had been involved, the advertisement would have been much more punchy and would achieve the result we all want. About that I dare say no more. The Minister in his opening comments said that he wanted quality to be the connecting thread that runs through all we do. That is fine. But how we get there is a different matter and the Bill is all about the devil being in the detail. The rhetoric is fine; the reality is extraordinarily complicated. A number of noble Lords—to many of whose views I will give great weight—will today offer important contributions, but I am particularly disappointed by the absence of the noble Lord, Lord Currie. He was responsible for the integration of the five regulators covering telecommunications, broadcasting, radio and the spectrum industries, as well as taking on new powers, in an extraordinarily effective way. The Minister is not surprised that there is a cynicism within the sector and that change fatigue is widespread as there have been so many reorganisations of the health service since 1997 at considerable cost, perhaps £3 billion. Two of the bodies to be merged, the Healthcare Commission and CSCI were created only in 2004. CSCI was announced just 17 days after one of its predecessor bodies—the National Care Standards Commission—began work. This helps the Minister to understand why he has an audience which is slightly jaundiced about these matters. The National Audit Office produced an excellent report recently which examined the creation of Ofcom and identified the lessons for public sector mergers of regulatory agencies. I commend the checklist of recommendations to the Minister. I hope that he will say that he has addressed all of them. They include basing the decision to merge on a balanced judgment of whether the projected benefits justify the costs of carrying out the merger; clearly identifying and accounting for the costs and setting a separate budget; carrying out targeted due diligence as early as possible; establishing relevant measurable benefits to be achieved, and measuring and monitoring progress against these objectives; ensuring regular communication with staff and stakeholders, reinforcing the merger rationale and providing regular updates; avoiding a decision-making vacuum by clearly defining those accountable for each phase; and appointing senior managers early, especially the board, chief executive, and finance and HR directors. I commend those lessons since it is evident that the result at Ofcom has been remarkably successful. I agree with the noble Lord, Lord Warner, about the appalling lack of detail about scope and regulatory matters. The rhetoric, again, is fine, but the sectors of social care, healthcare and mental health activities are extraordinarily different. I applaud the right reverend Prelate’s saying that the proposal will bring health and social care closer together, but will it? How do we know? Different sectors are being pushed together, but the detail of how that will work in practice leaves many of us needing to be convinced. The impressive Dame Denise Platt, chair of CSCI, commented that the Bill, "““lacks a clear set of objectives to work towards and hence the new body risks a loss of direction and a loss of focus on the views and experiences of the people who use services, their families and carers in particular””." Again, I say that the voice of carers is so important. I echo the points made about how GPs’ primary care organisations are to be included. They represent 35,000 separate organisations. I again draw attention to the scale of what the Government are seeking to do; that is, to move from small, singleton practices to massive medical institutions such as Barts and the Royal London—Imperial being the alma mater of the Minister. We also need much clearer boundaries of regulation. I endorse a point made by the Healthcare Commission about proportionality. If too many low-risk activities are brought within the regulator’s scope without a sufficient increase in resources, there will be a limited capacity to focus on the key risks and promote improvement. What consideration has the Minister given to providing other sources of assurance for lower-risk services? At the same time, is the Minister satisfied that the new framework will be sufficiently flexible to accommodate and respond to the rapid ongoing transformational change in service provision and patient pathways? It is well understood that, perversely, regulation can have a fossilising effect. It is enormously important that the new structures do not inhibit change and innovation. Is the Minister satisfied that the Bill reflects the fundamental shifts that are under way in the boundaries, organisation and delivery models in care services? We seem to be witnessing a move to 100 per cent foundation status for public sector hospitals and mental health trusts. There is likely to be more vertical integration between foundation trusts and primary care. New models and entrants are being developed in community and home-delivered care. Taken together, they will redefine the scope, shape, integration and aggregation of services, making it even more difficult to achieve a consistently level playing field for regulation. One or two other concerns were raised by my colleagues. The independence of the regulator is critical, as the noble Lord, Lord Patel, pointed out. For the same department both to fund and regulate the service is not ideal. Therefore, it is all the more important for there to be proper safeguards for the regulator’s independence; otherwise, where resources are constrained, difficulties can arise, as well as a perception of a conflict of interest, even if hotly denied in practice. The Minister needs to give more detail on penalties. Do we always expect deregistration to result in closure? I doubt it. In some of the big institutions, that would involve patients travelling long distances. The sums of money—one penalty is identified at £50,000—seem to have very little comparison, for example, with those measured by the Health and Safety Commission. The noble Lord made a point about the importance of commissioning. Surely that is critical. Will the CQC have powers to make specific recommendations to the primary care trust, the local authority, the local health authority and the Government? What will its powers be in relation to commissioning? I echo the points made about the importance of patients and users having a voice. The National Consumer Council rightly said that we do not expect the CQC to become a consumer advocate. But it needs to consider and involve the public in reaching decisions that affect us all. Healthcare is increasingly a partnership between the professionals and the public. Critically, in a mixed economy, the Minister's briefing states that, "““the public rightly expects the health and social care services they pay for through their taxes or privately to be safe and of the highest quality””." That again is so much easier said than done. Is the Minister content that the protection will be the same whether the care is privately or taxpayer funded? There is a real concern about the watering down of the regulator’s role to make information available. In conclusion, I would like the Minister to look again at the protection of the special expertise of the Mental Health Act Commission. The work that it does is entirely different from the work of the social care and the health regulators. It is critical that a sector that experiences 400 deaths a year, a quarter of which are said to be unlawful, does not lose and find itself ignored in this process of change. I welcome the Bill. It needs a great deal of attention. I hope that Sir Kenneth Calman, who has recently been appointed to chair the commission for the review of the Scotland Act, and who worked so closely with my noble friend Lady Cumberlege and me, is pleased that at long last the Public Health Act 1984 is to be updated and modernised.