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Health and Social Care Bill

My Lords, as the train manager apologised for the inconvenience caused by a faulty goods train ahead of us, my heart sank and the inevitable happened. I apologise to the Minister for missing his opening sentences today, despite running as fast as I could through the Underground. I appreciate the House allowing me to speak. I declare my interest as a person registered with the GMC and a practising clinician. This Bill is very important. It brings together three organisations which have effectively been doing a good job in recent years and have been seen to be driving up standards. However, I have a concern that the merging may have happened with undue haste. The new regulator’s £150 million budget will save possibly 25 to 30 per cent of the current cost of regulation. However, I feel that we risk losing the memory of those individual organisations—an organisation with a memory is often the key to the detection of problems. Piecing together the little bits of the jigsaw puzzle often reveals an imminent problem, which is preferable to waiting for one to explode across the headlines. It is partly for that reason that, like others who have spoken this afternoon, I feel it is important to have the principles in the Bill—a mission statement that includes principles that do not bind the commission to do, or not to do, one or other action. Rather, it should underpin the whole philosophy: equality; non-discrimination; the dissemination of good practice to drive up standards; and supporting research into different patterns of patient care to improve that and to cover the patients in whichever sector, be it healthcare or social or mental health. Patients move between providers and are often—as my noble friend Lady Campbell said so eloquently—simultaneously supported by more than one provider at the same time. Are we really sure that this legislation is proofed to look at the whole patient pathway? I turn to one of the most important sources of information; that is, the patients and users. I am not sure whether simply consulting them is enough, and I am certainly not at all convinced that carers are being adequately consulted here. Another group of carers that often finds it extremely difficult to express its opinion is that of underage carers. There are many underage carers in the country and I do not see them using any of the mechanisms laid out here at all. As the noble Baroness, Lady Pitkeathley, said, unpaid carers provide care that would be costed at about £87 billion, or the whole NHS budget for England. Carers have knowledge of the quality. They are the eyes and ears of the service—they observe the service on a day-to-day basis and are often the advocate, negotiator and funder for the person for whom that care is being provided. I am concerned that the Care Quality Commission may not be as independent as it ought to be. It should be able to publish completely independent reviews without the Secretary of State’s permission. It needs to be independent from Government to expose outcomes of poor funding, mistaken policy or inappropriate commissioning—after all, we spend £85 billion on commissioning. An encouraging improvement is probably not enough; I would prefer to see a duty to ensure that standards are taken up. Of course, as noble Lords have said, there must be minimum standards in place. However, that is not enough—it will not drive up quality of care. Quality in social care is measured by the patient experience, often without the hard outcomes that can be measured in healthcare. Philosophically, the process of inspection and driving up standards needs to be subtly different in approach. My noble friend Lady Campbell has brought her enormous experience to this area and I am sure she will bring it into further debates on the Bill. Like others, I question how those in self-funded care are protected. Are we setting up a two-tier social care system with unequal human rights, depending on where people’s funding comes from when they are in receipt of care? Another concern I have is the delay in the implementation of new processes that could leave a gap in which poor practice could grow unnoticed and where work to introduce improvements could go on the back burner for financial, or other, reasons. In this hiatus year before full implementation, can the Minister say how adverse incidents will be detected and investigated? My noble friend Lord Walton dealt in great depth with the change in regulation of healthcare professions and I agree with almost everything that he said. However, we must not lose the feedback that comes from learning through the investigation process and the ability to set standards so that when adjudication occurs all that has been gained during the investigation is forgotten. There are great complexities in different areas of clinical practice; medicine is not a universal field. I would certainly agree that technical knowledge needs to be represented on a panel. With a majority of lay members, there is a danger that the experience may be too limited. We have seen that happen with local research ethics committees, where lay members end up focusing on consent forms because they do not have the expertise to understand the science of the projects put before them. It is no more important to have that in-depth understanding than when a doctor’s long-term livelihood is on the line. In addition, perhaps the chair of the adjudication panel should just be appropriately trained rather than assuming that a legal qualification equates to appropriate training. The responsible officer system will probably work reasonably well in secondary care, but there are huge challenges in primary care and even more so for those working wholly in the private sector. The medical profession has grave concerns about the civil burden of proof. In part, I believe that is the fault of the GMC and the BMA, in that the situation has not been explained adequately to the profession as a whole. There is a problem in selling the change to the whole profession, but the profession must be keen to instigate remedial action very early against its own members. The last area I want to address is primary care itself. The regulation of primary care is difficult and the Bill seems to have avoided it, although the consultation document published today implies that primary care will be brought within the scope of the Bill. The Royal College of General Practitioners has done a lot of work on setting standards for general practice, but not all GPs are members of the college and the college has no levers on them. It is important that complaints, adverse incidents and near misses are collected and examined, as they are in secondary care. Otherwise there is a real danger that patients in the community could effectively be disempowered if there is poor governance of primary care services and no formalised mechanism for feedback, not only from patients but also from carers. The Picker Institute has suggested mechanisms such as the Service User Panel. I commend that concept to the House because we need feedback. Indeed, the devil is in the detail and we need to examine that detail.