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Health and Social Care Bill

My Lords, as the noble Baroness, Lady Finlay of Llandaff, ran past me on the Underground, I, too, feared that I would not be in time to hear the complete speech of my noble friend Lord Darzi in his opening address. I genuflect and grovel that I have to apologise for not hearing the whole of his speech. However, my time down from Chester today was usefully employed by talking to the Reverend Brian Holroyd of the Chester Abbeyfield Society which provides home care for older folk. He tells me that the noble Baroness, Lady Bottomley, is a marvellous chairman, and that he looks forward to welcoming the noble Baroness, Lady Neuberger, tomorrow when she addresses the Abbeyfield Society. I enter this field of which I am largely unknowledgeable. The Care Quality Commission brings together social care and the National Health Service, and I fear that the social care element will lose out at the expense of the National Health Service. I am also concerned about the role of small businesses in the social care area. While the care sector is, unlike the health service, a small independent sector organised for the large part, it is absolutely essential that the new CQC is able to differentiate properly between the sectors in its regulatory activity, and to accept that the two sectors are not cut from the same cloth. Indeed, CSCI notes in its State of Social Care Report for the years 2006-07, published in 2008, that there are some 80,500 care homes for adults of all ages, with more than 4,500 domiciliary care and nurses agencies registered with the commission, and a further 133 adult placement schemes around the country. There has been as slight decrease in the number of care homes—there are still 442,000 places—but there has been an increase of 112 home-care agencies over the past year. That adds up to about 24,000 services employing care staff. Most provide care directly, some organise care, and some do a combination of both. The essence to understand is that three in five are very small—that is, they employ 10 people or fewer—one in three are small, employing between 11 and 50 staff. Some 13 per cent are of a larger nature. Over recent years, there has been some consolidation in the care-home market resulting in fewer homes, but with the same number of places available. Just four operators own some 80,000 places out of that 442,000, compared to 10 operators in 2004. Yet again it should be noted that the remaining providers provide 70 per cent of the work. They are defined by having fewer than three homes. The CSCI publication on domiciliary care, Time to Care?, likened domiciliary care to a cottage industry. The domiciliary care sector is predominantly run by small providers, often highly dependent on a small number of council contracts. That has an impact on the workforce because, although found in smaller enterprises, it is as large as that found in the National Health Service. I hope that the Minister thoroughly understands that. Indeed, according to the Skills for Care 2008 report, there are something like 1.4 million people in paid employment; 1.3 million directly employed; 78,000 who were ““bank””, ““pool”” or agency staff; and some 100,000 people employed by recipients of direct payments. In contrast to healthcare, social care in the voluntary and private sectors is provided predominantly by the independent sector. It employs 70 per cent of that 1.3 million workforce; councils employ something like 16 per cent; and the NHS employs some 7 per cent. The age range is varied; 57 per cent of the workforce was aged 30 plus when they first worked in social care; and 32 per cent were aged 40 plus when they started in social care. So they come in relatively late. Social care is often seen as a sector with a very high turnover—60 per cent of the workforce has been working in care since 2000, but 40 per cent started before that, with 13 per cent starting before 1990. This all adds up to recognising that the sector of social care is differently composed from that of the NHS. If this commission is to bring the three previous commissions together, it is imperative that it recognises those differences exist. So some of the questions to my noble friend are these: when we have the Care Quality Commission, what efforts will be made to ensure that its members have knowledge of those different sectors? That is not just the sector that will require inspection of the various enterprises that find themselves there, but a sensitivity to those who run these small businesses. So it is not only the problems associated with the fact that these are small enterprises and therefore sometimes more vulnerable to the requirements to be properly inspected and brought up to full value and full standards, but also to have some sympathy to the understanding of those who are providing within that sector. Likewise, is the training of the staff who are going to inspect in this area adequate? Are we sure not only that they can spot the problems, but that they can be sympathetic to some of the real problems that emerge in that sector from time to time? Is the Minister happy with the expertise that he hopes to bring within the commission—that it will be able to fully recognise that small business sector? I, like others, think that a clear statement in the Bill of the regulatory objectives would be useful in many ways, not least so that the independent sector organisations understand what standards they have to recognise and live up to if they are to fulfil what we require of them. I shall end on the need to ensure that the human rights of people who find themselves in these smaller care homes and with care agencies and so on are respected. It has been brought to my notice that there is a loophole in the human rights legislation, which perhaps takes away some of the rights that those in the care system should be enjoying. Is the Minister content and happy that where a complaint is registered in, say, a smaller home, those who are not satisfied with the answers that they get in the first instance can ask the question higher up the ladder so that they ultimately get satisfaction? I hope that with those points in mind, and a reiteration that the workforce is as represented in the social care sector as it is in the healthcare sector, the Minister can go forward with the Government’s plans, to which I would otherwise give a generalised welcome.