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Health and Social Care Bill

My Lords, I welcome the Government’s commitment to reduce the number of regulatory and inspectorate bodies in the area of health. I declare an interest as a former Mental Health Act commissioner and current chairman of a foundation trust. I shall focus my remarks on Part 1 of the Health and Social Care Bill and the creation of the Care Quality Commission. I want to talk about the apparent duplication of the powers of the new body and those of Monitor, the independent regulator of foundation trusts. I then want to touch on a few other issues which I hope we shall address in Committee and on Report. I welcome the fact that the Care Quality Commission will be a patient and user-friendly organisation with a priority to safeguard service users and to help improve their experience of health and social care services. That will build on the very considerable improvements in recent years of the best health providers, and no doubt social care providers, in involving patients in planning services, staff selection and in raising standards across the piece. I come to this debate from a foundation trust perspective—I want to be straightforward about that. Again, I applaud the Government for introducing a healthcare model which, for the first time in my 25 years in the health service, has significantly improved the quality of services in many trusts up and down the country. It is vital that the regulatory and inspectorate system fully takes on board the implications of this massive change—I would call it a revolution—in the health provider organisational model. Unlike NHS trusts, foundation trusts have unitary boards accountable to their local constituencies through their locally elected boards of governors. They have legally binding contracts with their primary care trusts for the first time and are regulated by Monitor and inspected by the Healthcare Commission. We also report to our PCTs, and so on. As we know, there are some 53 inspectorates, monitoring and regulatory bodies. The trust that I chair has saved about £15million in efficiency savings during the past two years simply because we had to become efficient. Monitor demanded that. The degree of waste in the preceding era was absolutely breathtaking. I was not aware of it; I was part of the system, but had no idea of quite how inefficient the trust was. Now the trust is on a firm financial footing and is investing many millions of pounds in completely new and improved services. That is a first-time experience for me in more than 25 years. In the previous world of NHS trust status, we lived in a reporting nightmare. I asked our finance director for a note about this because I was aware of his experience. In a single year he had to provide six different, but very similar, annual plans: one to the Department of Health, another to NHS London, another to the strategic health authority as a due diligence exercise, another to Monitor and a further two to different firms of accountants. Each of the plans was based upon different assumptions, leading to different results, requiring different monitoring. You could not even send a duplicate to all six bodies; every single one of these lengthy, detailed reports had to be different. For the DoH and strategic health authority, these returns were monthly. As our finance director said, the work was mind-numbing, thwarted forward thinking, paralysed decision-making and defeated entrepreneurship. Other than that, he said, I suppose it was okay. Perhaps noble Lords will understand my anxiety that if this Bill remains unchanged, foundation trusts will face two regulators, Monitor and the CQC, which will have potentially overlapping powers. There will be a lack of clarity. We will once again be in this complete nightmare of duplicating reports and regulation, sending things in different directions, with nothing adding up and every single report being different. There are strong arguments for Monitor to retain the primary regulatory responsibility for NHS foundation trusts. It has proved remarkably effective in raising standards. It was quite painful to meet its requirements. We replaced five board members in order to meet the standards required. The Department of Health has argued that to provide a level playing field, all providers, including NHS, private and voluntary sector organisations, must meet the same standards and face intervention by the same body. Of course, all organisations should, ideally, meet the same standards, if those services can be compared in any realistic sense. I confess that I have my doubts about that. I am not convinced that a small domiciliary visiting service can really meet the same standards, for the sake of argument, as a foundation trust. I am sure that we will return to these issues in Committee. I turn briefly to the incorporation of the Mental Health Act Commission in the CQC. I have already declared an interest. I am not opposed to this move, so long as the distinctive role and focus of the Mental Health Act Commission in safeguarding the interests of all people detained under the Mental Health Act is preserved. These patients are unique in that they have lost their liberty. They are, in a sense, very much akin to prisoners in terms of how they feel about their health service. They have also lost the freedom to make decisions about their treatment. We know that the Government acknowledge the fine work done by the Mental Health Act Commission. Along with others, I will be seeking a change to the Bill to provide, perhaps, for a mental health sub-committee within the CQC, to make sure that a body of people within that organisation ensures that the interests and needs of detained patients are fully met in the future. A number of people have already spoken about carers, not surprisingly. On Report in the House of Commons, the Minister of State for Health, Ben Bradshaw, emphasised that, "““the Government believe that involving and listening to users, patients, their carers and the public will be a central responsibility for the new commission””.—[Official Report, Commons, 18/02/08; col. 77.]" Carers UK is rightly concerned that the Bill, as drafted, does not include any measures to achieve this vision. I hope we in this House will ensure that there will be full recognition in the Bill of the role of carers, and the duty of the CQC to consult and involve carers, along with patients and others. Finally, I turn to two related issues: the need for a set of guiding principles in the Bill—many other Peers have spoken about that—and a clear duty for the new organisation to drive up the quality of service across the country. At present the Bill has neither. Yet the Healthcare Commission and CSCI both have a duty to drive up quality, and the legislation establishing Ofsted and the Legal Services Board both included a strong statement of purpose for the organisations. Why should the Government leave the new organisation with a much narrower focus upon registration and inspection? Having been involved in running the Police Complaints Authority, I remember well that we vastly improved the quality and reputation of that organisation once we started producing reports on the general level of service, whether it was to do with deaths in custody, firearms incidents, the use of CS spray, or whatever. It was really only those reports that began to lift the quality of service across the police services. I am clear that this organisation must have that capacity—indeed, not just the capacity but the duty to provide those reports. I welcome the Health and Social Care Bill in principle, and believe that with the changes to which I have referred, and the many others suggested by Peers, this could be a fine piece of legislation.