NHS: Medical Competence and Skill

Lord Hunt of Kings Heath Excerpts

Wednesday 7th January 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to speak in my noble friend’s debate, and I warmly welcome it.

We would all pay tribute to the medical profession in the UK. We clearly have much of which to be proud. Equally, I agree with my noble friend that we should guard against the risk of complacency and always aim to sustain the current level of competence and try to enhance it.

I shall put to the Minister five points about training, continuing professional development, the use of simulation techniques, the adoption of new practices and medicines and the issue concerning medical negligence raised by noble friend Lord Turnberg.

I have been reading the Shape of Training report, led by Professor David Greenaway that looks at the future training requirements of doctors. It makes very sensible reading. I wonder whether the Minister can say something about the Government’s intentions on this and especially about the role of Health Education England. I draw his attention particularly to the fact that we need more doctors who are capable of providing general care in broad specialties across a range of different settings. The report states that this is being driven by a growing number of people with multiple co-morbidities, an ageing population, health inequalities and increasing patient expectations.

The Minister will recollect the work of the Royal College of Physicians on the new hospital, where it made the point that alongside specialists we need generalists who can co-ordinate care. Does the Minister think that that ought to be incorporated in the future training of our doctors? By definition, or certainly by implication, that means that greater prestige needs to be given to generalist doctors alongside the highly specialised ones.

I have also had the benefit of discussions with Dr Kieran Walsh of the BMJ in relation to medical education. The key point that he has put to me is that we need to look at inter-professional education. Healthcare professionals no longer work in silos, but in teams, but healthcare professional education still occurs mainly in silos. Again, are the Government working through Health Education England to do something about that?

I have had further discussions with Professor Stuart Carney, the dean of medical education at King’s College, concerning continuing professional development. As the Minister knows, this was introduced into the National Health Service some years ago but subsequently, of course, the revalidation of doctors was also introduced. Is he able to say something about the initial outcome of revalidation? There is a worry that both continuing professional development and revalidation can become a tick-box exercise rather than a focused approach to improving and enhancing the quality of medical practice. Perhaps he could say something about that. Again, that relates back to the Shape of Training report.

The fourth point I would like to raise is about the use of e-technology and simulation and how we can harness new technologies in the development of medical competence and skills. The Minister will know that around the country there are a number of simulation centres where doctors and other clinicians can take part in sessions that are designed to simulate clinical practice. That enables trainers to put doctors and other clinicians under pressure to see how they react when faced with multiple pressures at the same time. The problem is that it is all very voluntary at the moment. Can we look forward to a time when we can expect simulation training and regular updates to be a mandatory part of the life of doctors?

My fifth point is an issue that I have raised and discussed with the Minister on many occasions. In this country we have first-rate life sciences. We have a fantastic medical health technology and devices industry, but we know that the NHS is very slow to adopt new medicines and new techniques even though they have been proven to work. Will the Minister say a little bit about how we can encourage the NHS to move to adoption much more quickly? Can we use the new PPRS agreement on drug costs, for instance, as a way of incentivising the adoption of new medicines?

Finally, my noble friend Lord Turnberg asked about medical negligence. The Minister will know that there is an alarming rise in the payout of claims, which is probably unsustainable going forward. I cannot believe that the quality of medical practice is getting worse. It is something to do with the number of claimants and the action of the courts. I know that the medical defence organisations are very concerned, as well as the NHS Litigation Authority. In the short time that is available, is he able to say that this is something that the Government are at least keeping under review?

Alcohol-related Disease

Lord Hunt of Kings Heath Excerpts

Wednesday 17th December 2014 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what action they are taking to address the increase in alcohol-related disease.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, we have set out the Government’s approach to reducing the incidence of alcohol-related disease in the Government’s alcohol strategy. Our ambition is to radically reshape the approach to alcohol and reduce the number of people drinking to excess. We are seeing encouraging signs of change, with the first significant fall for some years in alcohol-related deaths in England in 2012.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am sure the whole House would wish me to congratulate the noble Earl on being nominated by Health Service Journal as the 29th most powerful person in the National Health Service.

[Noble Lords]

Hear, hear!

[Lord Hunt of Kings Heath]

Coming in at 95, I look on with admiration, but from some way behind. Did the noble Earl notice that a Mr Lynton Crosby came 50th in that list? Does he think that that reflects the rather close relationship between the Conservative Party and the drinks industry—and does that explain the outrageous delay in the publication of the Chief Medical Officer’s review of what safe levels of drinking should be?

[Earl Howe]

My Lords, I am sure the noble Lord would not expect me to agree with him on the position of Mr Crosby in relation to the drinks industry. We feel it right to engage with the industry because it is in a position of influence over consumers, and we have seen, through the responsibility deals, some real progress, which it has instigated at our prompting. I recognise the issue that the noble Lord raises on price. That, of course, is only one aspect of the issue of alcohol consumption and its prevention.

NHS: Medical Staff

Lord Hunt of Kings Heath Excerpts

Monday 15th December 2014 Lords Chamber

[Earl Howe]

My noble friend makes a very important point. As he will know, the UK signed the World Health Organization code of practice on the international recruitment of health personnel. My department worked together with the Department for International Development to produce a definitive list of developing countries—based on economic status and the availability of healthcare professionals—that should not be targeted for recruitment. He may like to know that the WHO is planning an assessment of the implementation of that code of practice and is due to report in 2016. However, we are mindful of the point made by my noble friend. Particularly with the Ebola crisis, it is important that we are sensitive to the serious issues that pertain in Sierra Leone in particular.

[Lord Hunt of Kings Heath (Lab)]

My Lords, given that, and given the Health Select Committee’s recommendation that although the contribution of overseas staff to the NHS should be celebrated, we should not be dependent on significant flows of trained staff from overseas, does the noble Earl still agree with the decision in 2012 to reduce the number of medical school training places by 2%? Does that not need reviewing?

[Earl Howe]

My Lords, as the noble Lord is aware, we rely on Health Education England to determine the number of training places that the NHS needs going forward, looking at not just the short term but also the medium to long term, informed by the work of the local education and training boards. That is as good a system as we believe we can get. Health Education England is properly funded to do that and we must rely on its expertise.

Learning Disabilities: Health and Care Services

Lord Hunt of Kings Heath Excerpts

Wednesday 3rd December 2014 Lords Chamber

[Earl Howe]

My Lords, the report contains a number of important recommendations which we will consider. This report was commissioned by NHS England for NHS England, to make recommendations for a national commissioning framework under which local commissioners would secure community-based support for people with learning disabilities and/or autism. It is an important report, it is right that we take a bit of time to digest it, and, together with NHS England, we are looking carefully to do just that.

[Lord Hunt of Kings Heath (Lab)]

My Lords, can the noble Earl clarify something? He knows that NHS England set a target of June 2014 to stop placing people with learning disabilities in inappropriate in-patient facilities. It appears that that has not been followed through by clinical commissioning groups. Can he confirm that, and say whether the Government will discuss with the regulator, the Care Quality Commission, whether a moratorium on the approval of new registrations for inappropriate in-patient facilities will be considered as part of the reforms that need to take place?

[Earl Howe]

The noble Lord is quite right that progress has not been nearly as swift as we, or indeed anyone, would have liked. NHS England has stated its ambition to achieve a 50% reduction in the number of people who were in in-patient beds on 1 April this year by March 2015. Although the latest data for November shows that some 2,600 people were in in-patient settings, the number of people with a transfer date has gone up by more than 1,100 in the last three months, so progress is being made. On CQC registration, the CQC may at any time decline to register or indeed cancel the registration of a provider where it is failing to comply with the registration requirements set out in law. That includes the new duty of candour and the fit and proper persons requirement, which came into effect at the end of last month.

HIV: Stigma

Lord Hunt of Kings Heath Excerpts

Monday 1st December 2014 Lords Chamber

[Earl Howe]

Yes, indeed, my Lords. I can tell my noble friend that there is such co-operation and constant communication between the public health authorities in England and the devolved Administrations on this, as on many other matters.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Earl made it clear in answer to my noble friend that academies are not subject to the core nature of the curriculum as regards sex and relationship education. As he will know, there have recently been a number of inspections by Ofsted that have shown up defects in the approach of schools to sex and relationship education. Surely that gives rise to concern that the issue of stigma is simply not being addressed properly in some schools. Is his department willing to take this up with Ofsted?

[Earl Howe]

I would be happy to do that.

HIV: Late Diagnosis

Lord Hunt of Kings Heath Excerpts

Monday 1st December 2014 Lords Chamber

[Earl Howe]

The noble and learned Baroness is absolutely right. Those who are at risk of partner violence are of course at greater risk of contracting a sexually transmitted disease. We know this to be true particularly in countries overseas. The work to combat domestic violence, which the noble and learned Baroness is very familiar with, continues. It is vital, not just in this area of work but more generally in the field of mental health, to ensure that women at risk of violence—particularly women—have a place of refuge and a source of advice.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am sure that the new money would be even more welcome if it had not consisted of quite a lot of old money rebadged. The noble Earl referred to the three-year HIV prevention campaign, which promoted testing and condom use. Perhaps I might ask him about how the campaign will go forward. Are the Government going to fund such a campaign and for how long, and can he say what proportion is going to be spent in the future compared with the past?

[Earl Howe]

My Lords, the Terrence Higgins Trust is the vehicle through which we conduct campaigns. Terrence Higgins has a three-year contract, which ends in March next year. We have yet to finalise all our spending commitments from April 2015. We expect that the funding for Terrence Higgins will have to be pared back by some measure because of the current funding constraints, but we are in discussion with Terrence Higgins about that.

Nursing and Midwifery (Amendment) Order 2014

Lord Hunt of Kings Heath Excerpts

Thursday 27th November 2014 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, I, too, am very grateful to the noble Earl, Lord Howe, for explaining the details of the order so clearly. However, he did not mention the Law Commission proposals for legislative changes relating to all health regulatory bodies. I note that the Explanatory Memorandum says that the Government will publish a response in due course, but I have to say that there is huge disappointment among the regulators that no Bill appeared this Session—not even one for pre-legislative scrutiny. Essentially, we are now faced with a series of Section 60 orders dealing with the regulatory bodies in an individual and piecemeal way, without the consistency and modernisation of the regulatory landscape that was promised by the Law Commission work. I hope that the noble Earl will be able to say a little more about when the Government will publish their response to the Law Commission proposals and perhaps give a little more information about how he sees the pipeline for Section 60 orders coming forward.

In particular, he will know that, in relation to the NMC, part of the Law Commission proposals were that there would be a reduction in the number of public hearings that have to take place. That would reduce the cost to the NMC and the time it takes to deal with cases. Given that we are not having primary legislation, is it the Government’s intention to bring forward as quickly as possible a Section 60 order in relation to that? As far as the proposals in this order are concerned, they seem sensible and unexceptional. I hope that they will lead to the NMC being able to be more efficient in its processes.

Having read the consultation document, I would just like to raise a couple of points on it. First, I will follow up what the noble Baroness, Lady Brinton, said about case examiners. The consultation document refers to a small number of people who are unsure about this proposal. I am particularly worried that as case examiners will be employees of the NMC, they will be target driven rather than acting as independent professionals. The consultation response from the Government says this will not be the case. It states:

“Although employed by NMC, Case Examiners will be both registrant and lay (non-registrant) and experienced senior decision makers who are used to making independent decisions”.

I very much endorse the comments of the noble Baroness, Lady Brinton, on training and the need for people to be brought in to provide fresh challenges. However, this issue about targets is a very important one, and I wonder whether the noble Earl can give me a reassurance that there will not be targets—even unseen ones—in relation to cases and their outcomes. Can he just say a little more about how we can ensure that case examiners will be wholly protected when they carry out their duties? If they are in a managed organisation, they will be accountable to a manager, and we need to have some assurance that there is not going to be interference by the hierarchy of the NMC in case examiners’ decisions.

I would like to ask about another point raised in the consultation document. One response was about the need for more diversity on panels,

“in particular a point that black, minority and ethnic (BME) employees are disproportionally represented within the disciplinary systems of both employers and regulators”.

The consultation says:

“These comments have been fed back to the NMC to consider”.

Has the NMC now given consideration to that issue?

Turning to the Deregulation Bill, the noble Earl was present at our debate last week and will know that we have some concerns that, according to a list issued apparently by the Government, the Professional Standards Authority is subject to the economic growth duty within that Bill. I do not expect the noble Earl to answer me on that today. But, given that the Professional Standards Authority is to be involved, can I take it that by implication that duty will fall also to the NMC, the GMC and other professional regulatory bodies? Obviously, we will come back to this issue when the Deregulation Bill returns on Report but we are finding it difficult to find out the list of organisations that the Government consider should be encompassed within it.

Of course, the issue is that there may be an impediment to the non-economic regulators taking regulatory action because they now have to consider the economic growth duty. In the main, that will apply more to the CQC when dealing with organisations than it will to the individual regulatory bodies. But as the Government think that the PSA is encompassed within the Bill, I would be interested in a response from the Government.

Will the noble Earl say something about the overall performance of the NMC? He will know that this has been the subject of some concern and indeed scrutiny by the Health Select Committee. At the most recent accountability hearing in 2013, the Health Select Committee concluded:

“The NMC is an organisation with a recent history of poor performance, including lack of focus on its core regulatory activities, financial mismanagement and long delays in processing Fitness to Practise cases”.

The PSA’s 2013 performance review of the nine healthcare regulators it oversees, which was published in July this year, stated that the NMC,

“is not yet meeting eight of the 24 Standards of Good Regulation”.

I know that in the 2013 accountability hearing the Health Select Committee concluded that,

“the NMC has made progress”—

indeed, I pay tribute to the chief executive and the chairman, who have done a lot to ensure that this happens—but it also says that,

“more progress is required before the NMC can be regarded as an effective regulator”.

Would the noble Earl care to comment on that?

The Select Committee also looked at the issue of revalidation. Following the introduction of revalidation for doctors, the need for revalidation for nurses is self-evident. The Health Select Committee says that it welcomes,

“the commitment of the NMC to introduce revalidation for nurses and midwives from the end of 2015”,

but that,

“it does not believe the NMC yet has a workable plan to deliver this commitment”.

That is the 2013 report of the accountability hearing. The Select Committee has not yet had the 2014 hearing, which I think will take place in January. Will the noble Earl update the Committee on whether he now thinks that the NMC has a workable plan?

Overall, this is a sensible order. We need to do everything we can to help the NMC improve its processes. I express my thanks to the current leadership of the NMC and the work that it has done. It clearly needs to do more and Parliament needs to be prepared to help it. If we are not going to have a substantive Bill, I would have thought it a priority to bring further Section 60 orders in relation to the Nursing and Midwifery Council, particularly on the question of whether we can help it streamline its fitness to practise hearings.

[Earl Howe]

My Lords, I am grateful to my noble friend and the noble Lord, Lord Hunt, for their questions and comments. My noble friend Lady Brinton asked for reassurance about the case examiners. Under the proposals, the two case examiners will independently review the evidence and then agree their decision. This is the same process as used by GMC case examiners, and I am not aware of any particular difficulties that it has encountered in this connection. If the case examiners cannot agree the decision, the case will then be referred to the investigating committee for determination, as I explained.

My noble friend asked about training of the case examiners. Two case examiners, one lay and one registered nurse or midwife, will consider an allegation of impairment of fitness to practise, whereas three investigating committee members are required at present. Co-ordinating meetings of the investigating committee members is time-consuming due to panel members having other commitments or requiring refreshed training. A case examiner will be a skilled role. They will develop expertise that will lead to greater consistency when making decisions because they will be considering a greater number of cases on a regular basis than individual members of a large pool of investigating committee members. This will speed up the fitness-to-practise process and result in reduced costs.

My noble friend asked whether the job specification of case examiners, as employees of the council, must specify that they carry out their roles without fear or favour and be truly free to make comments. Case examiners will be employed by the NMC, whereas investigating committee members, who currently consider allegations of fitness to practise, are chosen from a pool of around 100 individuals who provide their services to the NMC as independent contractors. But, once again, there is no reason to suppose that, as professional people, they will feel inhibited from voicing their full and frank views whenever they feel the need to do so. Despite their being employees, it is more than any professional’s self-esteem is worth to feel inhibited in that sense. It is a very responsible role. While the individuals will need to be carefully chosen, I have confidence that this arrangement will work.

My noble friend asked about the removal of the requirement for a registered medical practitioner to form part of the panel where health is an issue. We consider it more appropriate for medical advice to be provided by independent expert witnesses and medical reports. Having an independent medical witness will ensure that the panel remains detached from that part of the process and is therefore more able to make an independent decision so making the process more robust and transparent. This would ensure consistency between registration appeals and fitness-to-practise appeals.

The noble Lord, Lord Hunt, expressed concern that case examiners might be target driven, and this was an issue raised in the consultation. We do not believe that this will be the case. Although they will be employed by the NMC, case examiners will be both registrant and lay; that is, a registrant nurse or midwife and a lay person. Their role will be distinct; they will be responsible only for making an assessment of whether a registrant has a case to answer against an allegation that is made to the NMC that their fitness to practise is impaired. They will make their decisions impartially and independently, and based solely on the information provided for the case, including any representations made by the registrant. Any such decision would be made by a pair of case examiners. The NMC will seek to appoint people to these roles who have demonstrated sufficient skills and experience to make robust decisions. The NMC’s case examiner resource will be sufficient to ensure that all decisions will be considered on their merits, without any undue time pressure. Case examiners will not be involved in undertaking the fitness to practise investigation itself, nor in presenting cases at any final hearing.

Care Sector

Lord Hunt of Kings Heath Excerpts

Tuesday 25th November 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I, too, pay tribute to my noble friend Lady Kingsmill for her speech and for her report, which were both profound in their analysis of the crisis in care work and of what needs to be done. As she said, we know that people who receive care are very vulnerable. The fact is that the current situation means that in many cases they are not being treated with the care and attention that they deserve. All too often, their only source of support, care workers, are, as my noble friend said in her report,

“exhausted, unable to plan their own lives through insecure contracts, and unable to spend enough quality time with the person in receipt of care”.

As she says, they are invisible,

“under-valued, under-paid and under-trained. They don’t have the status of Nurses. They don’t have the status of Child-Minders. The sector is subject to weak regulation”.

The noble Baroness also said:

“The low status of Care Work and poor treatment of workers has led to a vicious downward spiral into one of the most difficult sectors for workers, with widespread exploitation”.

It is clear that the demographics that we face mean that the challenges in the care sector are going to grow. Our population is projected to continue ageing. The number of people aged 80 and over in the UK is projected to more than double to 6 million by mid-2037. As the noble Baroness, Lady Brinton, said, we will need 800,000 more people in the workforce to attempt to cope with the extra demand that is bound to be placed on the care sector. She, my noble friend Lord Lipsey and the noble Lord, Lord Birt, made the telling point about our absolute reliance on people from other countries to provide many of the care workers whom we need. That reliance will clearly continue, but we could do more to grow our own workforce. However, we will not do that without tackling the fundamentals identified by my noble friend.

I very much agree with my noble friend Lady Howells. She said that recommendations made by my noble friend Lady Kingsmill are eminently sensible and doable, including introducing a licence to practise for care managers—indeed, for all care workers. How many times have we called for the regulation of care workers in your Lordships’ House? Surely the noble Earl, Lord Howe, will be able to tell us that the Government now recognise that this is something that has to be done.

We need to enforce the national minimum wage and encourage the living wage. My noble friend Lady Andrews asked the Minister about HMRC’s weakness in monitoring and investigating cases where workers are paid less than the minimum wage. We look forward to a response. However, the point that I put to the Minister is that it is not just that workers in this industry do not receive what is due by law, but, because HMRC is not being proactive, we are essentially penalising the good companies—such as that of the noble Lord, Lord Curry—for doing the right thing. That is why it is important that HMRC must have a much more aggressive role.

My noble friend Lady Kingsmill says that we should ban exploitative zero-hours contracts and the 15-minute care slots, introduce a care charter, improve training standards and progression and, overall, improve the oversight and regulation of working conditions. All those things are surely right. We should also listen to my noble friend Lady Wheeler and the noble Baroness, Lady Gardner of Parkes, who focused on the role of social care personal assistants who are directly employed by service users. We would all recognise that personal budgets have a lot going for them, in giving people who are being cared for more control over their own lives. Many of them do the right thing, but Unison has shown, on a number of occasions, evidence of personal assistants being exploited by the people who have the budgets. We need to see some action in that regard.

We cannot talk about the plight of care workers without talking about funding. Many noble Lords referred to funding issues in local government and they are surely right to do so. My noble friend Lord McKenzie pointed out that local authorities are not just hugely challenged financially but are seeing their statutory responsibilities grow. Those of us who debated the Care Bill for many hours will understand that it is in this very sector that local authorities are going to see statutory responsibilities grow considerably, starting in the next few months. It is particularly worrying that the local authorities that are under the greatest pressure face the greatest reduction in spending power, due to the changes in formula that the Government have introduced.

My noble friend Lord Lipsey has challenged us to go beyond simply talking about local authority funding to thinking about the whole situation of the future funding of care. The noble Lord, Lord Curry, also drew attention to that. As we are shortly to debate many statutory instruments relating to the implementation of the Care Act, we are bound to come back to some of the fundamentals of funding long-term care in the future.

The noble Earl has never really responded to the point raised by my noble friend. It is a matter of a year or so until self-funders discover that they are subsidising people funded in homes by local authorities. We have yet to hear an answer from the Government about how the system will cope when people realise that they are paying much more than what a local authority pays for a similar service. As the cap operates, it will soon become apparent to them that the cap is not £72,000 at all but much larger. The cap will be based on what the local authority pays, but the self-funder will have to pay much more than that to reach the £72,000 cap. We are in for some interesting debates on that over the next few weeks. There is no doubt that the issue of funding will have to be tackled. There is also no doubt that part of the answer has to lie in a much more integrated approach between health and social care and the integration of budgets, which this side of the House is very much committed to.

It is not just a question of funding, however. My noble friend was right to say in her report that, if you look at the evidence of a weak and fragmented regulatory environment, irresponsible procurement practices by local authorities and poor workforce planning and management skills within care providers, there is still much that can be done that is not a question of resources. Through its leader, Ed Miliband, my own party has recently said that a Labour Government will legislate to give employees the legal right to a regular contract if they are working regular hours; to refuse demands that they must be available over and above their contracted hours; and to compensation when shifts are cancelled at short notice. We are also pledged to make CQC inspect the commissioning of care. I think that that answers the point raised by the noble Baroness, Lady Chisholm, about ensuring that local authorities check up on employment practices relating to care workers.

As my noble friend Lord Kennedy said, my noble friend Lady Kingsmill has done a noble service in shining a light on a hugely important question. We owe a huge debt to those working in the care sector—those paid to work there and those who volunteer. Despite the lousy conditions, every day many of them go the extra mile, as many noble Lords have mentioned. Surely the better we appreciate and support the contribution of the care workforce, the better the care will be. My noble friend has done a signal service to this nation with the report that she has produced and I hope very much that the Government will respond positively to it tonight.

NHS: Funding

Lord Hunt of Kings Heath Excerpts

Monday 17th November 2014 Lords Chamber

[Earl Howe]

My noble friend is right to highlight the role of public health. That is why many people are encouraged that health and well-being boards, which now oversee the planning and prioritisation of healthcare in their local areas, are taking those public health goals into account and building them into the strategic health assessments. So the co-ordination of healthcare and public health is in a much better position than it was before the reforms.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the Minister referred to the Better Care Fund. How does he respond to the criticisms made by the National Audit Office in the last few days? It said that the programme had poor management and hugely unrealistic expectations, and that it was not going to reduce emergency admissions. Can the Minister explain why the NAO concluded that the programme had no national leadership, limited risk analysis and no analysis of local planning capability?

[Earl Howe]

My Lords, that report is somewhat out of date. Plans have now been through the nationally consistent assurance review. The results have been published and shared with local areas, which have stated some clear ambitions. They are to have 163,000 fewer stays in A&E, to make £532 million savings for health and care services, and to have 101,000 fewer unnecessary delays spent in hospitals, along with other goals besides. We are very satisfied with progress reached in producing the Better Care Fund plans. Not all plans have been approved, but we are well on course.

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Lord Hunt of Kings Heath Excerpts

Wednesday 5th November 2014 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

At end insert “but that this House regrets that they undermine the protection of care home residents by removing current requirements in respect of complaints procedures, emergency procedures and choice of food”.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I should say right away that, overall, I welcome the thrust of these regulations. I am going to raise a number of points covered by my amendment to the Motion. I do so on the basis of broadly accepting the point raised by the Minister in relation to the CQC’s role and the way in which it is performing. However, there is particular concern about residents in care homes and the impact of the regulations which I would like to put to the Minister. My real concern is in respect of the three areas mentioned in my amendment in that, far from enhancing quality and public safety, the regulations actually reduce current protections in relation to complaint systems, food and emergency procedures.

I listened with great care to the Minister. He prayed in aid the remarks of Sir Robert Francis, and I will come back to them in a moment, but can the Minister also confirm that, in a sense, the regulations are a victim of the Government’s desire for lighter-touch regulation? The CQC clearly has a critical role in protecting some of the most vulnerable citizens in our country. This is not the moment for lighter-touch regulation. On any count, knowledge of the complaints system is important, particularly in view of concerns about standards of care in the health service and in many care homes. The current regulation states that the registered person must,

“bring the complaints system to the attention of service users and persons acting on their behalf in a suitable manner and format”.

The regulation goes on to require that,

“service users and those acting on their behalf,

are provided,

“with support to bring a complaint or make a comment, where such assistance is necessary”.

My understanding is that the Minister’s department is briefing that the new regulations are more outcome-focused and less specific about processes. However, if being less specific about processes means not telling people about them, it meets that test, I suppose. I also understand that his department is briefing that having an accessible and open culture is the same as having a specific duty to inform people about the complaints procedure.

However, the point I should like to put to your Lordships is that most residents and relatives have little idea of what to expect from a care home. Surely it is a relief to relatives and advocates when they are informed about these rights. It makes it easy for them to raise questions about care, knowing that that the regulations have the force of law and the matter cannot simply be left to local discretion. Few people comparing the two sets of regulations on rigour about complaints could argue that the proposed replacement is an improvement.

If one considers the tragic case of Winterbourne View—which I suspect a number of noble Lords will refer to—and other reports and the reports of the Health Service Commissioner, they continually emphasise that many providers’ stances on complaints are not fit for purpose. We know in relation to NHS complaints that there are continuous problems about people wondering whether they really can use them effectively. Almost all recent major care scandals have had their roots in people not being listened to or not knowing that they can complain. That is the basis of my major concern about these regulations.

Having emergency procedures in place seems pretty important, too. I do not understand the logic of deleting this important regulation. It may be that the Minister will say that it is covered by the new Regulation 17, but that states merely that, as part of good governance, the provider must establish systems or processes which enable the registered person to,

“assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity”.

That could easily be interpreted by providers to mean the normal, day-to-day risk assessments that they are required to carry out. I remind the Minister that care homes are pretty fragile organisations, often with very few qualified staff, and a significant proportion are without managers in place. That is why it would be much better to be absolutely explicit that emergency procedures should be in place.

--- Later in debate ---

I hope that I have been able to reassure the noble Lord, Lord Hunt, and all other noble Lords who have spoken sufficiently to make them feel confident that these regulations are the right way forward. I hope that the noble Lord will see fit to withdraw his amendment.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to all noble Lords who have taken part in this short but very interesting debate. I say to the noble Baroness, Lady Barker, that I agree with her on the importance of the duty of candour. We do not really have time to discuss this in detail, but alongside a statutory responsibility on duty of candour there is a need to address culture, particularly within the National Health Service. I am not convinced that the current regulators are helping the duty of candour. I think that we have a blame/risk-averse culture currently operating in the health service which is often driven from the centre. Alongside a duty of candour, we have to look at the need to change the culture to one which is far more collaborative in support of organisations dealing with very difficult issues.

I agree with the noble Baroness, too, on power of entry. Her point on prosecutions being based on breach of regulations was important, which is why the language is so important.

The Minister said that this was not a deregulatory measure. I presume that he is saying that the Department of Health is not chalking it up to the Cabinet Office as an example of deregulatory action. However, we have all had experience of deregulatory approaches taken by Governments and I have to say that some aspects of these regulations seem to have been influenced by a deregulatory approach—I know that the Minister rather chided my noble friend on this point. In the end, some regulations are essential and sometimes advice and guidance alone are simply not sufficient. The noble Baroness, Lady Howarth, acknowledged that there are strengths in the regulations, and I do not disagree with her about that. Sometimes there is a need to use regulations to be absolutely clear to those who are providing services and those receiving them. That is the case when it comes particularly to issues around food choice, emergency procedures and complaints.

The Minister explained why the Government have gone for what they describe as an outcome-based approach—I understand that—and he then quoted to us Regulation 17(2)(e), which states that the providers must,

“seek and act on feedback from relevant persons and other persons on the services provided in the carrying on of the regulated activity, for the purposes of continually evaluating and improving such services”.

That is elegantly written, as one would expect from his department, but it does not say to me that residents are going to be told how to make complaints. Let us think not about the chains but about the individually owned care home. I really doubt whether that would be very clear to the people in charge. It would have been better if it were explicit in the regulations.

I was going to ask the Minister if he would ensure that the CQC read the debate, but I am grateful to him for already giving us that assurance. I hope that when CQC inspectors go into care homes, they are clear that the regulations mean that there should be a proper choice of food, people should have complaints systems signposted to them, and there should be an emergency procedure in place.

This has been a very useful debate. I will withdraw my amendment. I wish the regulations godspeed. I support the CQC in its approach, but, when it comes to care homes, the CQC needs to be explicit both to the homes and the inspectors about the basic standards that need to be provided.

Amendment to the Motion withdrawn.