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Health and Social Care Bill

My Lords, I begin by declaring an interest as a member of Unison’s parliamentary group and as a General Medical Council fitness to practise panellist. While I welcome this Bill’s broad intent, it is clear that practicable changes in regulation on this scale can be rolled out only infrequently, so it is imperative that we get both the framework and the substance right at the outset. It is also important, as has been said, to draw on our collective experience and memory to date and—perhaps most crucially—to make a clear case for the advantages that will flow from the new regime. At its core, patients and service users must be persuaded that it will deliver safer and higher quality care. That is the test and the challenge. In this context I have some concerns, first, about how the lighter touch regulation will work in practice. As the chair of a housing association, I have seen first-hand how an impending visit from the regulator drives up standards in preparation for the assessment. I am not convinced that a written questionnaire, however detailed, can substitute for direct observation and contact with patients and staff. There are already concerns on the social care side that cuts in inspections are letting poor service providers off the hook. A recent survey of staff in this sector showed that 78 per cent felt that new arrangements were not improving care and 76 per cent thought that the methodology for risk assessment was flawed. In addition, 31 per cent said that they had been bullied to meet performance standards and 35 per cent knew of care services that had been registered but did not meet the national standards. That is not a happy picture and will not give much comfort to the relatives and users of care facilities, which is why there is still a need for regular and random visits to be a central feature of the new provisions. There is also a strong case for inspections to be automatically triggered under certain circumstances, such as the change of a care home manager, a new owner taking over a home or an unusual increase in staff turnover. We know from experience that these are often the first sign of problems and I hope that the Minister will feel able to consider this proposal sympathetically. Secondly, at a time when limited resources are available for the new merged Care Quality Commission, we need to be assured that the focus of activity will be toward those at greatest risk. There is a danger that by adding new groups to be covered by the regulator without increasing resources, the inspection regime will become even more stretched. Arguably, then, there is a strong case for including GPs in the provisions because of their widening responsibilities but perhaps less of a case for including dentists. Thirdly, I am concerned that the Bill as it stands differentiates between the regulation of the public and the private sectors. At a time when a wide variety of providers are entering the market, there is a strong case for the public to have unified assurances about the safety and quality of care, wherever it is provided—and whether by the public or private sector. However, the current proposals have different requirements for the NHS and the independent sector, and for primary and secondary care. Surely we should be aiming for an even-handed approach based on the risks to patients and service users. Equally, as has already been said, there is a strong case for the regulator to consider patient pathways where interdisciplinary packages of care are involved as all too often the real breakdowns occur between providers which can be both public and private. Fourthly, I share the concern expressed by others today about the changes to the complaints procedures, which mean that the regulator will no longer be responsible for responding to individual complaints about service providers. I agree very much with the research produced by Which? showing how reluctant patients are to complain and, in particular, how they fear that complaining could have a negative effect on future care. Those fears are arguably even more acute where longer term care is involved. Emphasising the need for local handling of complaints sounds laudable but, in practice, it could exacerbate the fear of coming forward. What is really needed is a fast-track route to a genuinely independent body that is able to investigate individual cases as well as to co-ordinate information about the overall range and nature of complaints. That would have the added advantage of providing redress for the 35 per cent of care and nursing home residents who fund their own care and cannot access the Local Government Ombudsman or the Health Service Ombudsman. It seems to me that at the heart of these proposals is a contradiction. On the one hand we want lighter touch regulation of service providers, while on the other hand we want more stringent regulation of professional staff. Staff now, quite rightly, have to go through periodic revaluation to carry on practicing while care providers will now have to produce less evidence of competence to continue working in the sector. I welcome the fact that the GMC has embraced the introduction of the more stringent civil standard of proof in fitness-to-practise cases but, as I have said before in this House, I am not entirely convinced that the other changes being proposed to adjudication are really justified. My own experience on fitness-to-practise panels is that the training and decision-making abilities of the panellists were of the highest standard and were rarely able to be successfully challenged in court. I remain to be convinced that the introduction of legally qualified chairs to fitness-to-practise hearings will enhance the quality of decision-making, and I share the GMC’s concern that legal advice and decision-making should remain separated. However, I understand that there could now be a more limited introduction of legally qualified chairs where the complexities of the case require it. I would certainly favour that approach. Finally, there is the small matter of the costs of setting up the Office of the Health Professions Adjudicator. I understand that undertakings have been given that the Government will meet the set-up and transitional costs of the OHPA, but there may well be other costs arising from the establishment of the new organisation that could fall on the GMC. I hope that the Minister will be able to confirm today that doctors will not be expected to fund those changes. In conclusion, as the variety and scope of service providers in the health and social care sectors continue to increase, there is clearly a value in having joined-up regulation. The challenge now is to provide a level playing field of quality standards combined with a duty to raise standards across the sector. I look forward to exploring ways that can be achieved as the debate on the Bill continues in the coming weeks.