Order for Second Reading read.
I beg to move, That the Bill be now read a Second time.
This is an important Bill introducing improved and integrated regulation of the health and social care system as well as enhancing the regulation of health professionals who work within it. It will help to assure safety and quality of care for all patients and service users. The Bill will also set new regulatory measures where they are necessary, and enhanced regulation where it is appropriate. It will expunge provisions that are out of date and that no longer meet the needs of patients and service users.
Those measures are essential to meet the challenges of 21st century health and social care provision. What was once the single biggest worry for patients—long waiting times—is now far less of a concern. Before we came to power it was common for patients to have to wait 18 months for operations. By the end of next year, patients can expect to wait a maximum of just 18 weeks between being referred by their GP and beginning their treatment. I stress that that will be the maximum waiting time. We expect that most patients will be treated within eight or nine weeks of referral. However, as the spectre of long waiting lists evaporates, patients’ expectations change with the times. Regulation of health and social care must keep pace with new demands, demographic change and medical advances.
This Bill will create a new integrated regulator for health and adult social care in England, the care quality commission, with tough new powers to inspect, investigate and intervene where providers fail to meet safety and quality requirements. Crucially, where infection control and hygiene are poor, the new commission will be able to act quickly and decisively. It will bring together functions from three existing statutory bodies—the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission—and will build on the expertise of those organisations.
I thank the Secretary of State for giving way at an early point in his speech. He will be aware that there is some concern in the social care sector that social care should have exactly the same status as health care under the new commission. Sadly, in the past, that partnership has been unequal. Will he assure me that the new commission will treat social care with the same importance as it does health care?
My hon. Friend raises the crucial issue with regard to the plan to merge the three current regulators. Social care must have parity in the new commission. That must be reflected on the board of the new commission and in everything that the commission does. I am pleased that she has given me the opportunity to reassert that that is the case, and that it needs to be the case. That point will be emphasised throughout the passage of the Bill.
I emphasise again that the Bill brings the vital role carried out by the Mental Health Act Commission into the heart of the care quality commission. That will strengthen the monitoring of the Mental Health Act 1983, and offer increased oversight of the treatment of patients subject to compulsory detention. I know that the MHAC places great emphasis on its visiting programme, covering each hospital and each ward that accepts detained patients. I expect the new commission to continue that approach.
The Government recently published their response to the consultation on the future regulation of health and adult social care in England. The consultation highlighted clear support for an independent, integrated regulator with a stronger focus on assuring safety and quality. For the first time, the regulation of the national health service, social care and independent sector providers will be carried out by the same organisation. As services become jointly commissioned and the boundaries between health and adult social care are broken down, it makes sense for our new integrated regulatory framework to work across those boundaries as well.
On the issue of joint commissioning, does the Secretary of State recognise that, as is so often the case, there is perhaps inadvertent confusion about whether the local authority or the primary care trust pays for a particular package of care? Within that confusion, it is often the patient—the consumer or end user; the person who needs services—who is subject to extra stress and burden, because they are being written to day after day by someone saying, “It is not our partnership; it is not our problem.” Such people are falling between two stools. Will the Secretary of State give a commitment to the House that the Bill will address those key issues?
I accept that things are not perfect. Practice-based commissioning, which is quite new, has still to attract genuine buy-in. Lots of people say that they operate practice-based commissioning, but it is not operating as we would like. The question is not just about the Bill, but about other measures, too. World-class commissioning, which we are working on and will launch shortly, is aimed at ensuring that people do not merely talk the talk on commissioning, but walk the walk.
The Secretary of State talked about the independence of the new care quality commission. If a chairman of the Healthcare Commission were required now, the appointment would be made by the Appointments Commission under the Health Act 2006. In the Bill, the Secretary of State proposes that the chairman and members of the care quality commission should be appointed by the Secretary of State. Why is he reducing the independence in the appointments process?
We will need to discuss that point as the Bill goes through the House. With a joint integrated commission, it is the Secretary of State’s role to make that appointment. It is a far more fundamental position, and such an approach is a necessary part of accountability to Parliament.
The new registration system for providers of health care and adult social care, which will cover both public and independent provision, will set the requirements that every registered organisation will need to meet. They will include requirements relating to infection control. With the creation of a new registration system for all registered activity, patients can rest assured that the care or treatment that they choose will be from providers who have demonstrated compliance with the same key safety and quality requirements, no matter where that treatment is provided.
I think that this is the appropriate point to mention that psychotherapists in the United Kingdom sometimes have a qualification, and sometimes do not. Sometimes that qualification is bogus; sometimes it is not. Sometimes they also have a medical qualification; sometimes they do not. The situation is a mess. Inexpert psychotherapy can be harmful to patients, who may think that they are receiving psychotherapy from someone who is properly trained. Indeed, the patient may think that the individual is a psychiatrist, which is entirely different—although some psychiatrists are psychotherapists, too. Will my right hon. Friend consider introducing regulation for psychotherapy under the auspices of the Bill?
I do my best.
We expect that the vast majority of providers will continue to demonstrate that they deliver quality services in a safe, clean environment. However, the Bill will introduce a wide range of enforcement powers that the commission will be able to use when registered providers fail to deliver safe, high quality care.
In the run-up to the Bill, the Government have talked about lightening the burden of regulation for health and social care providers. Is that not worrying? Providers such as one or two that provide elderly persons’ care in my constituency have closed down for failing to meet standards. We should be putting to the fore the safety and welfare of residents, not the burden on providers.
My hon. Friend makes a fair point. Of course, the new regime will involve a risk-based assessment, whereas previously providers received the same amount of treatment irrespective of whether they had a good record or even a record that was exemplary year after year. Usually the visits were determined by Government, not the regulators. The point of risk-based assessment is to ensure that organisations that have an excellent track record can experience either light-touch regulation or even no regulation, unless there is a problem. Meanwhile, the regulator can concentrate its attention on providers who have not met those standards. The two things go together. The essential point is that many organisations found themselves being visited by different regulators, and one regulator could carry out that function. I believe that that is an important step forward, without in any way compromising the important points raised by my hon. Friend.
Once any activity is registered, the commission can apply specific conditions to respond to specific risks, such as requiring a ward or service to be closed until safety or infection control requirements revert to the expected standard. The current Healthcare Commission can issue infection control improvement notices to NHS trusts only when it considers that the improvement will not be achieved in any other way. The new commission will not be restricted in that way. It will be able to visit trusts more frequently, close down wards and insist on their being thoroughly disinfected before they can be reopened. It could follow that up with more unannounced spot checks. It can also carry out annual infection control inspections of all acute trusts, using teams of specialist inspectors.
More generally, the commission will have the power to issue warning notices and penalty notices or instigate court proceedings to levy fines on any provider breaching registration requirements. When NHS bodies incur fines, the money will be returned to the local commissioners and reinvested to improve services, so that the local population does not lose out. The Bill also provides for the commission to undertake periodic assessments and reviews of care. The new commission will help reduce the burden of regulation on providers from itself and other public inspectorates through gate-keeping powers, which mirror those for other inspectorates, and through targeting activity where it is most needed.
The public expect value for money from their public services. In bringing together the regulation of health and adult social care in one regime, we will streamline regulatory activity and ensure that the commission manages its budget effectively, adopts a more independent and intelligent approach to regulation and provides a sharper focus on safety, quality and cleanliness.
I thought that I would ask this question before the Opposition asked it, because the streamlining to which my right hon. Friend refers means bringing together the Commission for Healthcare Audit and Inspection and the Commission for Social Care Inspection, which are two bodies—I appreciate that a third body is also included—that the Government statutorily established only four years ago. Why the change after only four years?
As usual, my hon. Friend asks a pertinent question. If we consider the history, we see that there was no regulation before 1999 apart from that under the Mental Health Act 1983, which was an important development that the previous Government introduced. When the two new regulators were introduced, there was a debate in Government about whether they should be merged immediately—whether we should have one regulator for the health service and for social care, while recognising that a separate regulator already existed for mental health. At the time, it was decided that that would be too much in one go, so the two separate organisations were set up but a process of evolution meant that, almost as soon as the Healthcare Commission was established in 2004, a proposal was made in 2005 to merge the two bodies. We are therefore considering a natural evolution. There will be no great change in the organisations’ functions, apart from the important change for which the Bill provides, which is all about integration. Taken together, the provisions will make regulation of providers more efficient and more responsive to people’s concerns. With social care and mental health as vital components, we will have a regulator that reflects the reality of integrated care delivered effectively to all patients, whatever their needs.
The Bill will also improve the regulation of the health professions and social care workers. Let me be clear from the outset that the overwhelming majority of health care professionals show remarkable expertise and exceptional commitment in their dealings with patients. They are as disturbed as we are about the rare occasions when a practitioner falls short of the high standards that they set themselves. That is why, as a society, we hold the professions in such high esteem and place so much trust in individual practitioners.
Earlier this year, the Government published the White Paper “Trust, Assurance and Safety”, which set out wide-ranging reforms to the way in which health professionals are regulated. Those reforms build on the far-reaching recommendations in Lady Janet Smith’s inquiry into Shipman and the report “Good doctors, safer patients” from the chief medical officer. Although the bulk of the legislation to implement the reforms will be effected through secondary legislation, the Bill will enact four key provisions.
I am grateful to the Secretary of State for giving way again. He will know how frequently the hope has been expressed in the House that when we legislate to follow up Dame Janet Smith’s recommendations we will do so not only in respect of health professional regulation, but in respect of coroners and death certification. It was clear in a debate in Westminster Hall back in July that it was the Government’s intention and hope to do that, but there is no coroners Bill in this Session to accompany the Health and Social Care Bill. Why not?
That is a matter for the usual channels. I do believe that we listed that Bill, but whether we shall find time for it in this Session is as much to do with the Opposition as it is to do with us. If we get the Health and Social Care Bill through speedily, we shall have more time available.
The Bill will enact four key measures. The first is to ensure that all the professional regulatory bodies use the civil standard of proof, so that the General Medical Council, the General Optical Council and the Nursing and Midwifery Council operate to a method consistent with the other eight health profession regulators. The second measure is to create an independent adjudicator, initially to adjudicate on fitness to practise cases for doctors, to enhance public and professional confidence in the impartiality of the GMC’s judgments. The third measure is to ensure that health care organisations employing or contracting with doctors appoint a responsible officer to identify and handle cases of poor professional performance by doctors, and to make recommendations to the GMC for revalidation. The fourth and final key measure is to pave the way for the creation of a new general pharmaceutical council.
The Bill will also make a number of other changes to arrangements relating to the composition of councils of the regulatory bodies, to the Council for Healthcare Regulatory Excellence and to the legislation currently governing the regulation of the social care work force.
Clearly the Committee, on which I do not expect to serve, would be the place to go into this point in great detail, but has the Secretary of State consulted the judges, who have laid down that if someone’s job was at risk, the civil standard of proof would not be high enough? They have laid down that in some serious cases the criminal standard ought to be used.
I cannot say whether we have consulted the judges; all I can say is that eight of the current regulatory bodies operate in accordance with the procedure that I have set out. Our consultation suggested that there was wide-ranging support, including, incidentally, from the GMC—the recommendation stemmed from Dame Janet Smith’s inquiry into Shipman—which believes that there should be a change from the criminal standard. The other argument, which is probably the clincher, is that if a case against an individual doctor was that serious, the criminal benchmark would apply. For all those reasons, the proposal has a widespread consensus behind it. I cannot say whether that consensus stretches right through the legal profession, but we have a strong enough argument to proceed on that basis.
My right hon. Friend mentioned ensuring that we have a sufficiently skilled and qualified work force. However, there are fears that work force registration will not be sufficiently enforced and that some people might slip through the net, possibly creating two-tier provision. Will he assure us that everyone in the work force will be properly registered and properly qualified?
Up to a point, Lord Copper. Given the procedures that we have set out in the Bill and the arrangements that apply quite separately, it is difficult to envisage anything further that we could do to ensure that. However, we are always willing to accept ideas and suggestions as we take the Bill through Committee. The Bill will also introduce a number of public health measures.
I am grateful to my right hon. Friend for giving way, Mr. Deputy Speaker, and I shall seek to catch your eye later in the debate. Just moments ago, I tabled early-day motion 386, which calls for citizens councils—as recommended in the NHS plan 2000—to be involved with the regulation of health care professionals. Does my right hon. Friend believe that the public, as patients, are sufficiently involved in the process of setting and reviewing the criteria for admission to the various professions and for continuing to practise in them? The evidence is that the public feel cut off from that process.
There are separate arrangements to ensure that the patient has a clear involvement. The other provision that arises from Dame Janet Smith’s inquiry into Shipman is that there will no longer be a majority of professionals on these bodies; there will be equality for lay people. That offers an important reassurance.
I thank my right hon. Friend for giving way with his usual smiling generosity. He referred a few moments ago to what might alliteratively be described as poor professional performance under this regulatory regime. Would that cover the surprising approach being taken by some GP practices, including some in my own constituency, and I believe by NHS Direct, of using 0845 numbers, which are a rip-off for the consumer—in this case, the patient? If this regulatory regime will not cover that practice, will he assure me that he will look into the matter? GPs are getting paid handsomely and properly by the state, yet some of them seem to wish to make extra money out of their patients’ phone bills.
My hon. Friend has raised an important point, but this is not a matter for the Bill. I am already well aware of the practice that he mentions, however, and we issued guidance earlier this year to say that patients should pay no more than the cost of a local call. Indeed, we believe that to charge in the way that he has described breaches the terms of the GP contract. The matter does not need the weight of this legislation, or the time that it would take to pass the measures, to deal with it.
The Secretary of State will be aware that many parts of the Bill will be subject to a legislative consent motion in the Scottish Parliament. Will he confirm my understanding that there has been excellent input by the Scottish Government and excellent consultation in Scotland on these measures? Is he content, as I am, that the provisions in the Bill are exactly what is needed?
I can confirm that there has been excellent co-operation, both before and after May 2007. That has really helped us to arrive at the provisions—particularly those on public health, which I shall come to in a second—that will ensure that the whole of the UK is well equipped.
The Bill introduces measures to help to prevent and control the spread of diseases that could present significant harm to human health caused by infection and contamination. The measures in the Bill will update the existing powers and provisions in the Public Health (Control of Diseases) Act 1984 relating to preventing and controlling disease. That legislation is clearly out of date. For instance, it allows us to regulate the risks from rag and bone men while remaining silent on the dangers of chemical and radioactive contamination.
The Bill seeks to bring our health protection into the 21st century by taking an all-hazards approach to health protection rather than by focusing only on specified diseases. That will allow a quick response to new or unknown diseases. I emphasise that the new legislation will be proportionate. We are updating the legislation to ensure that, while we have the powers needed to respond effectively to a public health threat, safeguards are written into the new legislation to ensure that the powers are used only when appropriate, and only to the extent necessary to secure the protection of public health.
The Bill will also support the health of pregnant women by introducing a new health in pregnancy grant. The grant will be a universal, one-off payment of £190, available to all expectant mothers ordinarily resident in the UK from the 25th week of their pregnancy. It will provide pregnant women with additional financial support towards meeting the costs of a healthy lifestyle, including diet, and other costs in the run-up to the birth.
There are also a number of small amendments in the Bill relating to the financial arrangements for pharmaceutical services; indemnity schemes in connection with the provision of health services; direct payments in lieu of provision of care services; repeal of the liable relatives rule; definition of ordinary residence as applied to the National Assistance Act 1948; payments to social enterprises; the creation of a national information governance board, ensuring that parents get automatic feedback about their child’s health through the national weighing and measuring programmes; and the functions of the Health Protection Agency in relation to biological substances.
There may be an increase in the number of complaints, but the new commission will not deal with them; they will go through the usual channels. We will stay in touch with the ombudsman to see whether staffing is sufficient to ensure that they can cope with any increase in work. I am sure that all the miscellaneous items that I have mentioned will receive due attention during the Bill’s passage through the House.
The Health and Social Care Bill will deliver a range of measures to assure the levels of quality and safe care that all patients and care service users have a right to expect. It will also introduce legislation that updates our current health protection powers to make them fit for purpose in the modern age and contribute to a healthier lifestyle for both expectant mothers and young children. I commend the Bill to the House.
I am grateful for the opportunity to speak on Second Reading. The Secretary of State says that the Bill is important. I do not dispute that it has important implications, but it seems that its importance was not such that the Prime Minister thought fit to refer to it at all at the start of the Gracious Speech debate. It is customary each year for at least one health Bills to be a flagship Bill, as it were. Unfortunately, this year the health Bill is not so much a flagship as a fleet auxiliary—useful measures grouped together in much less visible form that never acquire the status of a flagship.
I am afraid that this Bill in no way represents the changes in overall regulation that are required. After the 2005 election, the Government believed that there should be a wider review of regulation. They commissioned a review by Lord Currie of Marylebone and others, but they then more or less ignored it. They proceeded to publish consultation documents—frankly, inadequate ones—about the regulatory review, which culminated much later than originally intended in the document to which the Secretary of State referred.
This Bill implements only one aspect of all that—the part that relates to the Healthcare Commission—but it is perfectly clear that it will not achieve the regulatory changes necessary to provide assurance in the longer term to those providing services to the NHS. If one believed in the long-term role of the independent sector, for example, in supporting the NHS, one would need not only powers of inspection for the commission, but an independent regulator to undertake economic regulation in respect of market entry or market exit. Since 2003, the Government have failed to introduce legislation for the failure regime or for the exercise of powers relating to competition and pricing. None of that is in the Bill: it is not the legislation that we really need to provide either autonomy or proper accountability.
We have made it clear that we will introduce the necessary legislation in this Session and we will endeavour to ensure that it complements the aspects of the Bill that we support. In the course of the Bill’s passage, we can do certain things to make it more consistent with our long-term structure and vision for health care.
Before exploring some of the Government’s proposals in more detail, let me isolate one point. What is lacking in the Bill—for example, in respect of the structure of the care quality commission—is any formal structure to give a voice to patients and the users of services. Members—particularly those who are present—will recall that when legislation was introduced during the last parliamentary Session to abolish patients forums and set up local involvement networks, we thought it important for patients to have the national voice that was missing from that legislation. The same applies to social care for care users and, indeed, carers. This Bill provides no such national voice. Although clause 2 enjoins the care quality commission to have regard to the views of patients, no structure is built into the Bill to make that happen.
The Secretary of State intends the care quality commission to bear comparison with other regulators, but such structures are explicitly incorporated in many other regulating bodies. The Office of Communications, for instance, has a consumer panel, set up under the statute that inaugurated it, whose purpose is to acquire patients’ views. That is one of the reasons why, in the measures that we propose, we will make specific provision for HealthWatch—working alongside the Healthcare Commission, or the care quality commission, as it will become—to represent patients and express their views on the health service to the whole regulatory structure and the Secretary of State. The same could, of course, apply to those using social care.
Conservative Members will seek to amend this Bill to bring those principles into effect. Back in 2005, when Lord Currie of Marylebone presented his report to the then Secretary of State, he made it clear that such a national voice for patients was an essential part of a future structure.
The hon. Member for Wolverhampton, South-West (Rob Marris) kindly asked part of the question that I had intended to ask the Secretary of State. However, I recall from my membership of the Standing Committee considering what became the Health and Social Care (Community Health and Standards) Act 2003 that at that time we abolished the Commission for Health Improvement, which I think had been around for only about three years, in order to establish the Commission for Healthcare Audit and Inspection, now colloquially known as the Healthcare Commission. It does not seem as though any of those bodies had been entrenched for any length of time before being abolished, and the same is true of the Commission for Social Care Inspection. The National Care Standards Commission was abolished in the 2003 Act, CSCI was established, and no sooner is it up and running than we are to abolish it.
I would not wish the House to be in any sense misled. We believe that there has always been a strong case for those bodies to work side by side. We have always supported the proposition that we must try to break down the barriers between health and social care, and institutional divisions in the regulatory structure do not help that to happen. If we are to encourage, for example, the use of individual budgets and personalised care stretching across health and social care, it clearly makes sense for the regulatory bodies to work side by side.
On the commissioning side, the current position in Herefordshire, where the primary care trusts and the local authority have effectively merged their activities at executive level, suggests that a single organisation could be helpful. The relationship between Ofsted and CSCI in respect of children’s services is a good example.
While I am happy with the principle that the two bodies should be merged, the central issue—as the hon. Member for Blackpool, North and Fleetwood (Mrs. Humble) rightly said and as the Secretary of State rightly accepted—is that when social care and health care are brought together there is a natural, or perhaps unnatural, tendency constantly to prioritise health care to the exclusion of social care, and to make mental health a Cinderella within health care. There is an inherent danger that bringing everything together under one regulator will cause both the functions currently performed by the Mental Health Act Commission and those performed by CSCI to attract less priority than the current functions of the Healthcare Commission. I have no doubt that the more often we say that during the passage of this Bill, and the more persistent we are in Committee about the nature of the duties—we shall have to spell that out clearly, as the duties are expressed only in the vaguest terms in current legislation—the more likely we will be to ensure that this body delivers what is intended. In my experience, the more independent a regulator needs to be, the more important it is that their duties, including the factors to which they must have regard, are spelled out in legislation; otherwise, that independence will be undermined—or if there is independence, the more likely it will be that the regulator behaves in ways that do not attract the support of the House.
Will the hon. Gentleman also reflect, however, on the fact that too often this House has added so many details to regulatory legislation that instead of regulators being able independently to work out the most effective form of regulation, processes have become bureaucratic and tedious and there has been a failure to achieve the overall objective? The House must give the powers to regulators so that they are able to use them effectively, rather than try to tie them down so much that they spend their time ticking boxes instead of understanding what is happening on the ground and ensuring that people can get hold of the information they need to know whether things are working or not.
I am interested in what the right hon. Lady says because under other legislation enacted by this Government the view has been that it is rather important to set out those duties—in relation to an energy regulator, for example, that it is important to set out the duty on security of supply, the duty on promoting competition and the interests of consumers and the duty on the achievement of environmental objectives. I do not think it would have helped to have said, “We are setting up a regulator who has a duty for the improvement of energy services,” which is more or less what is happening in the current context: a regulator is being set up with the duty to improve health and social care.
How is the regulator to define that? The answer, which is built into clause 2, is that it is to be defined by reference to the Secretary of State and Government policies. Clause 2(4) re-incorporates into legislation what is currently section 130 of the National Health Service Act 2006 in respect of the Healthcare Commission. [Interruption.] Yes, I am showing off now. That pretty much says that both the Healthcare Commission and CSCI have statutory provisions under which they must have regard to the policies of the Secretary of State. Therefore, when the Secretary of State says, “This body will be independent,” we will take a very close look at what that means. Strictly speaking, “independence” should mean independently appointed, with independent duties established by Parliament, and with an ability to pursue the duties of, for example, safety, quality, efficiency and effectiveness to whatever conclusion. It should not mean having that compromised by the way in which the Secretary of State sets out his policies.
It is evident that much of the burdensome regulation that the Healthcare Commission has to undertake in relation to health care providers is the direct consequence of the way in which successive Secretaries of State have set out the targets that they want health care providers to meet. Therefore, the target culture is a direct precursor of the burden of regulation. It is more important for us to be focused on the delivery of the duties of quality, safety and efficiency instead of having that overridden by the Secretary of State. I am sorry that that has been such a long digression, but it has been a helpful one from my point of view, so I am grateful to the right hon. Lady.
It is important to pursue the question of risk-based regulation. Although the Secretary of State says that it will be risk based, I am unclear whether the Bill delivers that. It is certainly intended to be proportionate to the risk that is to be safeguarded, but it could easily be said that all health care providers—depending on what they do—have more or less the same kind of risks attached to what they do. We must look hard at this Bill to incorporate into it the principles of risk-based assessment and regulation, because they are not in it yet. I hope that as the Bill progresses we can ensure that the care quality commission has not only a specific role as a national voice for patients, but specific ways in which it takes into account the interests of patients, care service users and carers.
The Secretary of State talked about health care-associated infections. This feels a little like the groundhog day of health legislation, because it is almost exactly two years ago that I was standing here responding to the Secretary of State’s predecessor, who was telling us that the 2006 legislation was the last word in regulation, and that the Healthcare Commission was to have these new powers. In fact, the commission can carry out unannounced inspections. At the time, the Government looked at and we discussed the question of fines. They concluded that the best thing to do was not to introduce them, and that it was better to have a process of improvement notices.
I do not know what evaluation has taken place. The code of practice set up under the 2006 legislation came into force on 1 October 2006. We are less than a year down the line of the introduction of that code of practice, and although I am not aware of how many inspections there have been, there were an initial 15 inspections for compliance with the code of practice. I do not know to what extent the Secretary of State regards this as a successful or a failed regime. One improvement notice has been served, against Chase Farm hospital, and we have yet to have others.
I simply do not know what the evidence base is for the Government’s concluding that their policy failed and that they must have a new one. The cynics among us might suspect that in fact, from the Secretary of State’s point of view, a new Secretary of State must equal a new policy, and a new policy must equal new activity. Perhaps when he asked the Department, “What is it that we have not done that we could do in respect of health care-associated infections?”, he was simply served up something that his predecessor had rejected. That is often how these things happen, and I am afraid that this looks a lot like that.
I should be very disappointed if it were felt that this Bill or the role of the care quality commission itself was a sufficient response to the demands of tackling infection control. We debated this issue last week, so I will not travel down all the paths associated with it, but it is clear that on the Maidstone and Tunbridge Wells NHS Trust, for example, the Secretary of State is hiding behind the Healthcare Commission as though it were not an inspectorate coming in to establish to what extent a body is failing in its duty to provide care; instead, he seems to be regarding it as a performance management organisation. However, it is not; as things stand, it is the strategic health authority’s responsibility to manage the performance of the Maidstone and Tunbridge Wells trust, and the Department of Health has line management responsibility for the performance of the SHA. However, given the events surrounding the trust, it looks to me as though performance management was ignored.
The Secretary of State talked about world-class commissioning. However, the primary care trust clearly subcontracted its responsibility for infection control and quality to the health protection unit. Effectively, the PCT played no role in determining the quality of the services being provided to patients at Maidstone and Tunbridge Wells. Likewise, the SHA subcontracted its responsibility to the health protection unit, which did not get involved until an outbreak had been notified. Even then, it did not have the necessary powers. So the Secretary of State needs to think hard, and we should think hard, not only about how we strengthen the role of an inspectorate in assessing from the outside where things are going wrong, but about ensuring that performance management works more effectively inside the national health service, because at the moment, it clearly does not.
I take the hon. Gentleman’s point, but may I also suggest that he think hard, as many of us do, about trying to strike the right balance between decentralisation and local control, and national priorities for a national health service? Both our parties struggle with that.
An example of that balance can be seen with hospital-acquired infections. If asked, people say that they want local control of their health facilities. They say that until something goes wrong or until they perceive a disparity of provision, which is sometimes called a postcode lottery. They then say, “We are worse off than the people next door” and they ask why somebody, usually Whitehall or the Government, does not sort it out. Hard thinking is required to strike that balance, and the Conservative party needs to do some of that.
We have done quite a lot of hard thinking about this matter. I do not know whether the hon. Gentleman has had occasion to read the autonomy and accountability white paper that we published in May, but it expressly addresses these issues. For example, it makes it clear that the independent allocation of resources to try to achieve greater equivalence in access to health care across the country relative to the burden of disease is important. Figures that I published yesterday demonstrating the wide disparities across the country in expenditure per cancer patient are largely associated with that. Even if one were to equalise the allocation of resources relative to the burden of disease, it would not mean that the same amount would be spent, because different parts of the country would have different priorities. I do not believe that we could ever reach the point where the centre could mandate how much is spent, but a nationally funded national health service should have a national allocation system that is at least geared towards providing equivalent access to health care services for people in the same circumstances.
We can also be clear that commissioning guidelines and standards can be established nationally, which is why the Bill reproduces existing legislation. Standards should be set nationally, and the care quality commission, whose task is to assess performance against those standards and provide information on that, should be in place. I do not know what the Government’s view is for the future, but I think that the role of patient choice and decentralised commissioning then becomes all the more effective, because performance against those national standards can be taken into account and can help to drive the local response in terms of what is being delivered. That is our view, but heaven only knows where the Government stand on patient choice.
I thank the hon. Gentleman for that thoughtful response. I have not read every word of that shadow white paper, and he will correct me if I am wrong about this next point. I recall that after its publication in May the Conservative party proposed a policy of increased localism—I use that term in a broad sense—and at the same time called for a national moratorium on any proposals to close an accident and emergency hospital unit in England. That gets the balance a bit wrong; I am not saying that the Government necessarily have that balance right, but that is why I was politely suggesting that he should think a little harder about this balance between localism and centralism.
No, it is not a local process. This is why the hon. Gentleman is misdirecting himself. Our proposal to impose a moratorium on what is happening is us saying that we will not countenance—or would not have countenanced had we taken office following an election—a process whereby national clinical directors and Ministers in the Department of Health wander around telling people what they should be doing. They should be going to places such as the constituency of my hon. Friend the Member for Worthing, West (Peter Bottomley), where the national clinical director is saying to people that there has to be a drainage population of 400,000 plus in order to provide an accident and emergency service. That is clearly not justified by the evidence. Subsequent material, such as the report published by the Academy of Medical Royal Colleges, makes it perfectly clear that accident and emergency departments serving smaller populations are entirely viable.
What I am saying is entirely consistent, because I believe that the clinical evidence and the decision making should combine locally. The clinical evidence will not all be derived locally, and indeed much of it will be prepared by the professions nationally, but it has to be interpreted into local circumstances and be the product of local decisions. Under this Government, it is not the product of local decisions but of national influence and determinations from the centre.
I am grateful for my hon. Friend’s reference to the situation at Worthing and Southlands hospital. I think that the primary care trust will now have another serious look at the issue, and I am grateful to the Secretary of State if he was quietly involved in that, as I suspect he was. I put it to my hon. Friend that it is wrong for national standards to come from papers written by tsars that are not peer-reviewed, contain no evidence and are, in effect, a series of anecdotes.
I agree, and that is at the heart of the issue that we have presented. It is unacceptable for local managers to receive documents from the Department of Health that are not evidence-based or peer-reviewed, and are inconsistent with the professions’ collective view. Such documents are presented as though they are clinically driven and have to be translated locally, just because they are written by someone who happens to work in the Department. That is not acceptable.
I was talking about accident and emergency departments, so I meant George Alberti’s document. However, the same point can be made about Roger Boyle’s document. He presented an argument about the need to centralise stroke services, but—as the Secretary of State knows—there is no model for doing so. There is no basis for knowing what the necessary catchment population should be, for either acute care of stroke or the concentration of services for primary angioplasty. The pilot studies on primary angioplasty have not reported, been peer reviewed or provided evidence. But Roger Boyle produces his document, and the Prime Minister and others stand at the Dispatch Box and say that services must be centralised on that basis. That is why we propose a moratorium: so that such issues—the design of stroke services or cardiac interventions based on evidence—can be structured locally on the basis of evidence, rather than assertions from the Department of Health.
I shall now return to the subject of the Bill, Mr. Deputy Speaker. The House will recall the passage of the Mental Health Act 2007, and it is extraordinarily important that the introduction of community treatment orders—and the extent of compulsion under them—is the subject of independent scrutiny. That will be the role of the Mental Health Act Commission, and I hope that it will be made clear during the passage of this Bill that that should happen.
When the Minister of State winds up, I hope that he will tell us when we may expect the proposed section 60 order on the governance of the General Medical Council, because it would be helpful to consider that alongside the broader proposals to shift towards parity in lay and professional participation. The Secretary of State will know that we have accepted some of the principles. We accept the principle of parity, but we do so in the context of helping to support confidence in professional self-regulation, not helping to undermine it. I hope that during the passage of the Bill we will explore carefully the proper role of the office of the health professions adjudicator and why it has to be operated independently from the GMC. If we believe in professional self-regulation, we should be able to structure the regulation in a way that keeps the functions of investigation and adjudication within one body, even if they are functionally separate.
The Department appears to assume that responsible officers will be in place in April 2009, but that is a heroic assumption. For a start, I am not sure that it is right to assume that in most cases the medical directors of primary care trusts should be the responsible officers.
I believe so. I understand that the date is April 2009, but if I am wrong the Minister will let us know. I think the time scale is too rapid—it is a heroic assumption.
Should a responsible officer combine clinical governance responsibility with the assumption of part of the management responsibility? Let us consider that point in the context of primary care. If GPs as contracting providers have a developing relationship with the primary care trust, is it necessarily right that the responsible officer as a member of the PCT board should also have responsibility for their clinical governance arrangements? I have no doubt that clinical governance should be improved and strengthened, even more so in primary care than in secondary care, but we must do that in a way that commands the greatest possible confidence among the professions. It is important that clinical governance be conducted by somebody who has only that responsibility, with no risk of conflict of interest with other responsibilities.
I repeat my question about the scrutiny process of the professional practice of doctors. On the one hand a revalidation structure is being set up; on the other, where there is the possibility of serious failings there are fitness to practise investigations and, in the middle, there is the question of what happens when someone has difficulties in their professional practice that are not such as would give rise to an investigation by the GMC. Such cases are pursued by the National Clinical Assessment Authority, alongside the National Patient Safety Agency. I have never understood why. If there is a spectrum of issues relating to professional practice, from making sure that people are up to date to the correction of serious problems, one body should be responsible for all of them.
On standard of proof, the Opposition Front-Bench team have made it clear that we accept in principle that we should move from a criminal to a civil standard. The medical profession is concerned that the loss of livelihood of its members would be accomplished on the basis of a more-likely-than-not calculation and, it would argue, on evidence that might not substantiate the loss of livelihood and its resulting impact on the individual. I do not think the profession is right about that; it is important to recognise that in practice a graduated scale is applied by tribunals, and courts, even with a civil standard of proof, which relates the nature of the evidential test—the quality of the evidence provided—to the penalty that would eventuate from the conclusion that somebody was guilty of an offence.
We need to make it clear in the legislation that that is the case, to try to set minds at rest, and that it is true, as my hon. Friend the Member for Worthing, West in effect said in his intervention on the Secretary of State, that when a court is presented with the proposition that somebody will lose their livelihood—which is very significant for doctors, as they may not easily be able to pursue another career—there must be almost a criminal standard of proof before that result is achieved. I think that that is pretty much what the court was saying—so there is a precedent for saying that the civil standard of proof must be applied in a way that is sensitive to the nature of both the allegations and the evidence. As we incorporate that provision in the statute, we must attempt to give the medical profession that assurance.
The hon. Gentleman is making a balanced argument, but if we use the civil standard of proof how will he ensure that we word legislation that allows us to slide up the scale towards the criminal standard for some offences and not for others? How can we make that clear without it leading to more and more legislation as people take tribunals or the GMC to court because they did not get the answer they wanted?
The hon. Gentleman’s expertise is medical, not legal, but those who write the legislation will have to try to ensure that the guidelines are at least very clear. We will have to see to what extent they can be incorporated directly into the primary legislation and in the schedules to it, but I am sure that the House will have noted his declaration of interest in these matters—or not.
I will not delay the House on the part of the Bill dealing with public health. On the face of it, the updating is pretty straightforward. The powers requiring people to be quarantined or to submit to medical examination if they are infectious have been extended quite a long way, so we need to ensure that the safeguards exist. I have no doubt that there should be such powers but, taking the wider view, I just wish that we also had public health legislation that helped to achieve the things that we have proposed to create a much stronger separately funded public health service that works with local authorities to deliver better on our public health objectives.
The Secretary of State will know that only a third of the dedicated public budget of £300 million that the Government have allocated since the White Paper “Choosing Health: Making healthy choices easier” has been spent on public health objectives. He will also recall that Ara Darzi’s document on “A Framework for Action” in London expressly sets out the fact that primary care trusts spend on public health in inverse relation to their deprivation. For example, Tower Hamlets, which is one of the most deprived areas in London, spends £6 a year on preventive health spending.
I beg the hon. Gentleman’s pardon. Tower Hamlets spends £6 per head, whereas the Bromley primary care trust, which is not among the most deprived, spends £33 per head per year on its preventive spend. Frankly, that is an outrage.
The Secretary of State did not dwell at length on the issue of health in pregnancy. My hon. Friend the Member for Eddisbury (Mr. O'Brien) has reminded me that I am taking up some time, but I will talk about more things than the Secretary of State mentioned; we need to mention some things that he did not. The health in pregnancy grant was announced in the 2006 pre-Budget report as something that would merely bring forward child benefit payments to pregnancy, but it now has a slightly different character. It is not designed in precisely the same way.
I have two questions about the grant. Is it to be administered entirely by Her Majesty’s Revenue and Customs and will it be paid for by the Treasury directly? I will not dwell on HMRC’s administrative potential and the nature of the data that will have to be supplied, when they will be supplied, by whom they will be supplied and to whom HMRC may supply them. The House needs an answer because there is no impact assessment to tell us not only what the overall costs will be but who will pay the cost of implementation of £8.4 million in the next financial year.
The Secretary of State seems to think that the health in pregnancy grant is the best way of spending the relatively large sum of £175 million a year to support nutrition in pregnancy. May I direct him to the draft guidance from the National Institute for Health and Clinical Excellence that was published just a couple of months ago? Paragraph 3.5 says:
“Interventions which ensure that a woman is nutritionally equipped for pregnancy are likely to have the greatest effect if delivered before conception and during the first 12 weeks”.
Later the guidance considers the gaps in the evidence and says:
“There is a lack of well-designed interventions on how to…improve the nutritional status of women before and during pregnancy”.
“There is a lack of well-designed studies that have evaluated the use of food vouchers to encourage health eating.”
Let us leave aside the simple fact that the grant may be spent by pregnant women on things other than what is necessary for their diet. The guidance also gives rise to the question as to whether this is a well-calculated and evidence-based intervention even in terms of improving diet.
That brings us to question of weighing and measuring children. It has always been our argument that not only should children be weighed and measured, but there should be an effective follow-up. I see nothing yet in the Bill—perhaps the Secretary of State will add more in terms of policy—about an adequate follow-up. The report from the National Institute for Health and Clinical Excellence clearly shows that universal interventions by midwives, health visitors and school nurses are critical. However, what is the actual situation? Let us consider health visitors. In 2004 there were 10,137 full-time equivalent health visitors. By 2006, that figure had reduced to 9,376. It is clearly not possible for us to deliver the kind of improvements in childhood obesity that we want to see, when the number of health visitors is declining.
Let us consider what the Government have said about school nurses. The then Minister of State said in March 2006:
“Because we know school nurses make such a difference, we want at least one, full-time qualified nurse working with every cluster of primary schools and their related secondary school by 2010.”
There are 3,343 secondary schools in England. According to the Minister of State, Department of Health, the hon. Member for Exeter (Mr. Bradshaw) on 23 October this year, there were 815 full-time equivalent nurses with the appropriate nursing qualification working in England. So we are nearly 2,500 short of what is required by— [Interruption.] The hon. Member for Wolverhampton, South-West says from a sedentary position, “Cluster.” There are 3,343 secondary schools. The policy is for one full-time qualified school nurse per secondary school and its cluster of primary schools. I am using the number of secondary schools, so the comparison is entirely valid.
On the social enterprise investment fund, I welcome what the Government are proposing, and the benefit of that. We already know the potential impact of social enterprise in the health care sphere, if only by reference to what hospices do for palliative and end-of-life care. In that context, it is astonishing that the Government are going down this path without at least ensuring that they have provided, through the publication of the end-of-life care strategy and the development of the tariff for palliative care, a full cost-recovery structure for hospices, if they wish to take it up, for the delivery of end-of-life and palliative services. Hospices are social enterprises that do a remarkable amount, and they should at least have the option—even if they are not required to do this—of providing services to the NHS in a fully supported way.
The Government propose, under clause 134, to extend direct payments. We have always welcomed that. Some Members will recall that when the “Our health, our care, our say” White Paper was published on 30 January 2006—excuse me, Mr. Deputy Speaker, but I am going to quote myself—I said:
“Will the Government legislate to allow direct payments to extend across health and social care, so that patients with long-term conditions can control the management of their care?”
The then Secretary of State replied:
“The hon. Gentleman…mentioned the extension of direct payments, not only to social care but to health. That sounds like the revival of the patient’s passport.”—[Official Report, 30 January 2006; Vol. 442, c. 26-29.]
In the White Paper, the Government said:
“It has been suggested that we should extend the principle of individual budgets and direct payments to the NHS. We do not propose to do so, since we believe this would compromise the founding principle of the NHS that care should be free at the point of need.”
I did not agree with them then and I do not agree with them now. Interestingly, Lord Darzi said in his interim report:
“we need to learn how to support and allow eligible service users increasingly to design their own tailored care and support packages. This could include personal budgets that include NHS resources.”
The Government have done a complete U-turn. Will they say today that they will incorporate in the Bill the necessary provisions to allow individual budgets and direct payments to extend across health and social care, in the way that Lord Darzi has made clear he now supports?
Finally, on the pharmacy contract, there is a proposal to transfer the global sum into the hands of primary care trusts. Will the Secretary of State—or the Minister of State, when he replies to the debate—acknowledge that thus far there has been a pitiful take-up of most of the advance services that would have delivered precisely what the Prime Minister, when he became Prime Minister, said that he wanted— pharmacies that offer more screening, more lifestyle support and more opportunities for people to access sources of advice and information about their health?
That is not happening under the current pharmacy contract. It needs to be transferred from the Government to the primary care trusts, and the Government should make sure that there are sufficient incentives for the pharmacy contract to do what was intended, as distinct from pharmacies getting a global sum as a consequence of the manipulation of category M list prices.
This is a portmanteau Bill. The Secretary of State has arrived with his bag full of lots of tricks, most of which have been in gestation in the Department since long before he arrived there. None the less, some of them will be useful. Many of them will require scrutiny during the passage of the Bill, but none of them, as put forward by the Government, constitute the long-term sustainable vision of how health and social care can be regulated in a way that will deliver the improvements in standards that we all so long for.
I declare an interest. In 1999 I was appointed, along with two other Members of the House, to the doctors’ regulatory body, the General Medical Council, and in 2003 I was reappointed to the new council by the National Health Service Appointments Commission, and I still sit on that body.
I am pleased that the Bill is before the House and that we are considering the introduction of a care quality commission, which will have tough powers to deal with the safety and quality of care. We have just heard the hon. Member for South Cambridgeshire (Mr. Lansley) speaking from the Opposition Front Bench about how important performance management is in the national health service. I agree with him about that. It is difficult to grasp who is responsible for what. Over time, a regulator that deals with the quality of care could answer many questions about the differences in treatment that patients—our constituents—sometimes experience between one establishment and another.
Also, bringing together the regulation of health, adult social care and mental health care should ensure a more consistent approach to regulation. The regulation of social care will represent a large part of the work of the new regulatory body. Hopefully, it will implement our manifesto commitment to strengthen clinical governance and the regulation of health care professionals.
During the last general election when I was a candidate and not a Member of the House, I spent an evening in Tameside talking to a group of people who were relatives of the victims of Dr. Harold Shipman. After talking to them for two or three hours, the need for a change in regulation was all too apparent. Because of the dreadful consequences that their families had faced, those people knew more about regulation than many health professionals or Members of the House. Health and social care professionals should be more accountable to the public as well. I hope that that is implicit in the aims of the Bill.
The merger of relatively new regulatory bodies will have to be handled carefully. There is always a danger of losing effectiveness when change takes place, as people are left wondering whether their position will exist in a few months. The Select Committee on Health, on which I sit, has often found that change tends to take people’s mind off what they should be doing. Care must be taken that that does not happen when the merger proposals in the Bill are implemented.
Having been on the General Medical Council for many years, I have more than an outside interest in these matters. I am interested in the doctors’ approach to the Bill. The British Medical Association is moving a little closer to where it should be as the representative of the vast majority of doctors. The tone of its press releases a few months ago, one of which was headed “Doctors’ leader warns of ‘assault’ on the medical profession”, has changed. I am pleased that it has, because I do not think that there is an assault on the professionals at all. I frequently meet doctors up and down the land who do not feel that what is happening is an assault on the profession.
I am sure that some members of the medical profession would, rightly or wrongly, feel threatened by a change in the burden of proof from the criminal to the civil standard. We need a supportive culture that emphasises the education and retraining of doctors who have difficulties and encourages doctors to speak out about problems that they see for themselves and others. If we are to produce that supportive culture, which in the end would lead to better patient care, we have to make sure that doctors do not feel threatened.
I agree entirely; my hon. Friend is a practising doctor and knows such things better than I. However, what I mentioned has been the case for all the years that I have been on the General Medical Council—and probably since the council was first brought into being. Sadly, that does not mean that it is the actual practice on many occasions. That is why some of the detail in the Bill is important.
Let me cite two things that the BMA said in its brief for this debate:
“The BMA also has concerns about the removal of the adjudication function from the General Medical Council…and therefore the creation of a separate body, the Office of the Health Professions Adjudicator. We are also very worried about the role of the proposed ‘responsible officers’ because we see them as having a conflict of interest between their various roles.”
It also says:
“The BMA strongly opposes Clause 104 which imposes a requirement for all the health professional regulatory bodies and the new Office of the Health Professions Adjudicator to use the civil standard of proof (the balance of probabilities)”—
that has just been alluded to—
“in fitness to practise cases. The General Medical Council currently uses the criminal standard (beyond reasonable doubt). It would be an injustice to remove a doctor’s livelihood based on a lower standard of proof than is used currently.”
I can only say that I think that the BMA is wrong. Having discussed the issue with numerous doctors, I also think that many doctors think so too. However, one thing in the brief that I agree with—I want to put it on the record as well, and I hope that the whole House agrees with it—comes on page 1:
“The vast majority of doctors perform well and safely, and acknowledge that it is imperative that patients are protected from the small number of cases of unsafe doctors. The BMA therefore fully supports measures that promote excellence in medical practice and that help to reduce instances of poor standards, negligence or criminality among doctors.”
I agree wholeheartedly with the first part of that: the vast majority of doctors do look after us as we would expect, and we should have confidence in them.
May I use this question to prompt the Minister later, although that may require a bit of work? Does the right hon. Member for Rother Valley (Mr. Barron), the Chairman of the Health Committee, agree that the civil standard in professional cases rises up towards the criminal level? There are not two totally separate standards. We could get advice on this, but I do not think that the BMA need be too worried if the current acceptance of what the judge has laid down for civil standards does indeed rise if a doctor’s ability to go on practising is at stake.
That is absolutely true. I have the evidence that the General Medical Council received on that matter. There were two clear cases in which the civil standard was increased on that basis. In one, the allegations were made under the civil process, but they were serious allegations that needed serious action. I shall allude to that issue further in a few minutes.
What is taking place is not new in respect of quitea lot of the regulation of doctors, of which I have experience. In 2006, the GMC published a package of proposals designed to deliver a modern framework of independent and accountable medical regulation,and the Government’s White Paper, “Trust, Assurance, Safety: The Regulation of Health Professions in the 21st Century”, reflected a lot of the GMC’s own paper. The GMC is confident that its current arrangements for adjudication lead to consistent and high-quality decisions. The hon. Member for South Cambridgeshire referred to separate adjudication and said that the BMA might have concerns in that regard. As things stand, the GMC would not disagree with that. It has changed its adjudication panels massively since I first became a member in 1999. I was involved in the changes in governance between 1999 and 2003 that made adjudication as independent from the statutory body as it could be.
The BMA’s parliamentary briefing says on page 3:
“The BMA does not believe the case has been made for establishing a separate body and does not accept that the medical profession should lose the authority to regulate itself.”
It is fundamentally wrong for the BMA to use words like that. In my experience of the GMC, it has not been a case of doctors protecting doctors—far from it. In the years prior to 2003 when I sat on fitness to practise panels, there was never a case of lay members versus doctors in terms of wanting to come to a decision on a doctor. Such words do not do the profession any good. Sadly, some people still think, wrongly, that it is about doctors protecting doctors—no wonder, when one sees such words in briefings given to Members of this House for the purposes of a debate.
The GMC has accepted the Government’s decision to establish an independent adjudication body and will use its expertise to help to ensure the smooth transition from where we are now. When we changed the GMC’s governance in 2003, the one thing that we could not do was to appeal against any decisions by the adjudication panels, because we had made them independent. I remember going to meetings of the adjudication panels as a lay member, trying to talk the case through with them, and then saying, in a nice way, “We think you got that decision wrong.” At least the GMC will now be able to appeal against decisions of the adjudication panels. The GMC is pleased that the Government have accepted its view that it should have the right of appeal, have made it clear that the GMC remains the owner of professional standards, and are protecting in legislation the relationship between the new body and the GMC in the application of the principles of good medical practice. Good medical practice is what the GMC judges all its doctors against, and the fact that it remains in statute is a very good thing.
The GMC believes that patients’ best interests are best served by independent and accountable regulation. The GMC must be independent of Government as the dominant provider of health care in the UK, independent of domination by any single group, and publicly accountable to Parliament. In response to the hon. Member for South Cambridgeshire, who said that a draft section 60 order is likely to be published at some stage, it was published today, and it looks into some of the areas that he mentioned. The GMC’s current model of governance is that there should be parity between medical and lay members without an in-built majority on the council for either. We should aim for an equal proportion of medical and lay council members—a 50:50 split—on the new council that will emerge from the section 60 order.
I remember when we moved from a GMC of 124 members, which was by and large dysfunctional—it was a bit like being in Parliament except that Division bells did not ring so we never took a decision on anything; at least that happens here, as dysfunctional a body as we may or may not be—to a membership of 35. A 50:50 split is right and proper. We will see how that will work in the next few days in the details of the section 60 order. The GMC should also have a balanced composition that reflects those who receive and provide health care across the UK—patients and the public, doctors, the NHS and other health care providers, medical schools and medical royal colleges. That is crucial. If it cannot be done numerically, it can be done by ensuring that people on the council have the breadth of experience to play a useful role.
The civil standard of proof will apply in any case without the Bill. The GMC decided that quite a long time ago, upsetting the profession well before Ministers did so by publishing the Bill. That mode of travel was suggested by Dame Janet Smith, and it will apply whether we change regulation procedures or not. I will loan my hon. Friend the Member for Dartford (Dr. Stoate) my legal opinion on that and he can read it for himself. The GMC’s president, Sir Graeme Catto, is on record as saying that he does not believe that the change will result in more doctors being erased from the register, but it should make it easier to impose appropriate restrictions on a doctor’s practice where that is necessary to protect patients. Removing a doctor from the register is a very serious matter, and where the consequences are loss of livelihood, the rigour of the criminal standard of proof, or a standard close to it, is clearly appropriate. On the other hand, the consequences of sanctions other than erasure may be less profound, and that could be taken into account in the evidence required to reach a finding on the civil standard of proof. That approach is wholly consistent with protecting patients and the public interest, and with being fair to doctors.
The GMC’s legal advice makes it clear that the civil standard of proof is not a rigid criterion by which facts are to be judged, but is to be tailored to the facts of any given case. It is often said that the more serious the facts alleged, the more cogent and compelling will be the evidence required. The application of the civil standard of proof more accurately reflects the true function of the GMC fitness to practise panel. Having had years of sitting on those panels, I completely agree. We would never go for the more serious actions against a doctor without good cause or consider one standard and one only. The panel is not a criminal court and it does not apply the criminal law. In particular, it is questionable whether it is appropriate to retain the criminal standard of proof in a protective rather than criminal jurisdiction, especially when the concerns relate to a doctor’s health or performance. That is crucial. The process is there to help the doctor, but often it is too far down the line.
Does the right hon. Gentleman agree that the recent section 60 order provides a lot more flexibility to look at cases where a doctor may have had an ill-health problem, and that whereas previously the only option in such cases had been to strike them off, a more sympathetic approach can now be taken?
It has always been the case that the GMC has tried to consider health and performance issues differently, but they may become relevant when the case is presented. When adjudication goes to the new body, recognising issues to do with doctors’ health and performance will be as important as the question of what might have happened, although I accept that that depends on the seriousness of the incident.
The great majority of professional tribunals in various walks of life apply the civil standard of proof; and it is already used by the majority of other health care regulators. During recent consultation—I say this to my hon. Friend the Member for Dartford—several other regulators that apply it confirmed that it did not present them with any undue difficulty. In those circumstances, there should no grounds for the fear put about by representative bodies. The Court of Appeal recently explained that the use of the criminal standard of proof in areas other than the criminal law is very much the exception. The GMC is committed to ensuring that procedures are fair, objective, transparent and free from unfair discrimination, and that they command the confidence and support of all those who receive and provide health care throughout the UK. I believe that the application of the civil standard of proof is consistent with the protection of patients and the public interest, and it is fair to doctors at the same time. I am pleased that such a process will take place.
I would like to move on to the issue of responsible officers, which was mentioned by the BMA and in the speech of the hon. Member for South Cambridgeshire. There is a need for greater coherence and co-ordination across all levels of medical regulation, particularly locally. Heath care providers have a clear responsibility for effective clinical governance arrangements that ensure that the fitness for purpose of those whom they employ, or contract to provide services, is good. They also must be effective channels of communication between national and local systems, which includes ensuring clarity with regard to matters that need to be addressed locally, and those that should be dealt with by the national regulator.
While with the GMC, I sat a lot on the interim orders committee before 2003. It would consider a lot of cases without taking final decisions on them. There were cases—not very often—that quite clearly should have been dealt with at a local level; doctors did not need that stress in their lives, or the threat of having to go in front of their regulatory body. Quite often, an exchange of letters was enough to deal with such cases. That raises the question why such cases progressed to the regulatory body in London when most people thought that they could have been handled at a local level.
The establishment of responsible officers means that for the first time there will be a nominated individual at a local level with a statutory responsibility for fitness to practise matters. Based on my experience, that is a good thing not just for the profession, but for our constituents and for patients. It will build up a confidence that is sadly sometimes not there. The role of responsible officers includes monitoring the conduct and performance of doctors, ensuring that appropriate action is taken in response to concerns about conduct and performance and evaluating the fitness to practise of medical practitioners. That role is clearly, therefore, linked to revalidation.
Revalidation was promoted by the GMC for many years, sometimes with the support of the profession, sometimes not so much. We need to ensure that doctors working in our health care system are up to date. To be on the register, all they need to do is go through medical school, get on the register, get their number, go into work, and—provided that they do nothing wrong for the next 30 years—they can retire on an NHS pension. Even if they are independent contractors, like my hon. Friend the Member for Dartford, they can retire on an NHS pension, provided that they do nothing wrong. There is no measure to ensure that doctors keep up to speed with new medical practice or to ensure that they are using better services for patients to give them better quality of care than they would have received in years gone by. Having an in situ responsible officer overseeing revalidation, which will come in separately to the Bill or regulations—
For the record, we have had reappraisal in general practice for some time and hospital doctors certainly undergo extensive revalidation in order to meet clinical governance regulations. I would not want the House to think that there is no onus on doctors to remain up to date.
That is true, but it depends on who is doing the appraisal. I am not sure whether it would be right for someone who works alongside a person to do their appraisal.
I shall finish on this note, given that my hon. Friend tempts me. I represent a constituency that is covered by the Rotherham district general hospital, which was visited by the famous Gerry Robinson and a BBC crew earlier this year. That was on national television, and my hon. Friend may recall two consultants in the ophthalmic department. One of them would do cataracts only under a general anaesthetic and the other one would do them only under a local anaesthetic. The latter consultant would normally do about six or seven in any one session, and the other would do only three. It is true to say that to some extent the royal colleges might defend that, although the risk of using general anaesthetic is greater than that of using local anaesthetic, but that consultant did not use it because he would not. I thought that that was wholly wrong, and I am pleased to say that he is about to begin a long and happy retirement from the NHS.
Everyone is obliged to keep up to speed with what is happening in their profession, and Members of this House, of all parties, do so all the time. I do not put in my manifesto what I put in it when I stood for election in 1983. I do not say things in this House that I used to say in 1983 either. We all have a duty to ensure that we keep up to speed in many areas, and the medical profession should have as well. I am pleased to have had the opportunity to relate some of my experience, and explain what the GMC feels about some areas of the Bill. It is a great opportunity for us to advance health care in this country, and have health care that looks after patients, the public interest and doctors as well. I am pleased to support the Bill.
We welcome the broad aims of the Bill, but as always, the devil will be in the detail when we get to Committee. The thought has already been expressed that it is bit of a shame that we are faced with yet another reorganisation. The Healthcare Commission is fairly new, as is the Commission for Social Care Inspection. It would have made more sense to have brought them together three years ago, as the Liberal Democrats suggested at that time. All parties favour a more joined-up approach, but we have to guard against a one-size-fits-all mentality. When we are talking about regulation, we need to remember that what a large acute hospital requires is very different from what might be required when regulating a small domiciliary care agency. Both are important in their own way, but they require different approaches.
It is also worth putting it on record that the existing regulators have done some excellent work in their differing fields. Concerns have already been expressed that the new body should retain a strong focus on social care. There are fears of health domination. I do not know how well founded those fears are, but health issues are much more high profile in the media agenda and sometimes in this place, so we must do all we can to ensure that social care does not become the poor relation.
The CSCI has expressed concern that any additional duties for the care quality commission should be adequately and separately funded, such as any duties that might stem from the current focus on hospital-acquired infections, which are also covered in the Bill. Otherwise, it is feared that resources could be squeezed from social care to fund that health agenda. Although we all support money being spent on ensuring that our hospitals are clean and safe, that must not come at the expense of the vulnerable and elderly.
The CSCI has been fully committed to paying great attention to the views of those who are—I hate the phrase—service users, and their families and carers. It is essential that we retain that process at all costs. Indeed, the Healthcare Commission has been moving in that direction latterly, but there is little in the Bill to provide assurances that the patient’s voice, or even that of the carer, will be heard. We can learn a lot from those experiences.
The Mental Health Act Commission provides for regular unannounced visits to those detained under the Mental Health Act 2007. The frequency of those visits needs to be protected, because it is a crucial tool in ensuring that the rights of the 45,000 people detained each year are protected. Can the Minister confirm what measures will be put in place to ensure that those standards are not eroded?
It is not clear how the funding will work out, which is causing some concern. The regulatory impact assessment discussed a number of different models, but a wide range of possible costs and savings would apply. We need to be clearer about the detail as we approach the Committee stage. The Royal College of Psychiatrists has raised concerns about some services being squeezed and about whether some of the monitoring and notification work that it undertakes will continue in its present form.
It would be helpful if the CQC could continue the work of the MHAC in reporting admissions, discharges, deaths and other relevant information on behalf of detained patients. Many organisations suggest a rights-based approach and hint that the Bill has missed a bit of a trick. Clause 44 is welcome, in as much as it gives the CQC the facility to conduct special reviews and investigations into health and social care of a certain type or as provided for certain groups. It is important to consider those with learning disabilities, particularly given the recent example of the Cornwall Partnership NHS Trust. Over the years, concerns were raised by families and carers, and if the CSCI’s approach had been taken, those views would perhaps have been taken more seriously earlier. Only when a joint investigation was undertaken by the Healthcare Commission and the CSCI were 64 cases of abuse uncovered that had happened over the past five years. We must remember the background: the trust was given a high star rating while people in its care were abused. We need to ensure through the fine detail of the Bill that such an incident will not happen again. A facility to consider how an organisation treated a group of people with a disability or whether people with a mental health problem were being treated differently would have been welcome.
The Bill provides us with an opportunity to close the human rights loophole. Nine out of 10 care homes are privately owned or in the charitable sector, and so human rights legislation does not extend to them. Attempts were made during the passage of the Equality Act 2006 to try to introduce some legislation on that matter, but the Government resisted. I hope that they will be more sympathetically disposed on this occasion. Residents of independently run care homes who experience rights abuses cannot challenge their care home provider.
One example of bad treatment that breaches human rights is that of older people in care homes who are told that they have to move to a different home at short notice, which engages article 8 of the European convention on human rights. Other examples often include disputes about care home visitor hours, restrictions on social relationships and even refusal to allow cohabitation with partners in the same care home. Those examples are at one level, and cases of elder abuse that occur on another level in care homes are, thankfully, a minority. Any abuse should be taken seriously, and the individual should have a chance to challenge it.
I turn now to professional regulation. I must declare an interest as a member of the Royal Pharmaceutical Society, which will be no more as a result of the Bill. It is somewhat unusual in that it regulates the pharmacy profession but also acts as a representative body. In the post-Shipman era, we are moving towards councils with a parity between professional and lay members. It is difficult for such a body to represent the profession adequately. The Bill will set up a general pharmaceutical council, which is a move that most in the profession now support. However, there are concerns that the move is being foisted on the profession by the Government. Most of the profession seems to feel that there has been a lack of help in setting up a professional body or something akin to a royal college, as suggested by Lord Carter in the Carter review.
The balance of any health care regulatory council is important. Instinctively, it would seem right that there should at least be a lay majority. That would help the public to have a greater trust in the regulators. There is a perception, whether it is right or wrong—I think that it is wrong—that the professions look after their own. I contend that the opposite is the case. The vast majority of professionals in any health profession do a good job and they do not want rotten apples in the barrel. The professions are quite hard on themselves. As we are always told that an evidence base is needed for introducing any change in regulation and policy, what evidence is there that a lay majority gives a better outcome for patients? I do not think that there is any. Dame Janet Smith and the Shipman inquiry suggested it, but there is no hard evidence that it is better for patients.
More controversial is clause 104, which seeks to reduce the standard of proof for doctors, nurses and midwives and the General Optical Council from the criminal to the civil. Most of the noise has been made by the British Medical Association on behalf of doctors. However, the General Medical Council, also on behalf of doctors, planned to introduce such a measure anyway, as was mentioned by the right hon. Member for Rother Valley (Mr. Barron). I understand the concerns of individual practitioners, who must instinctively feel that if they transgress they are at greater risk of losing their livelihood. That must add stress and worry. Other health care regulators, including those in my profession, have managed the civil standard of proof well. It is a serious step to strike a health professional off the register, and it is not done unless there is an overwhelming balance of evidence. It is not done on the balance of probabilities. People have to be sure. We also forget that the people who sit on such committees and listen and decide the outcomes are human too. They apply a standard of fairness in such cases.
Although the right hon. Member for Rother Valley welcomed the concept of responsible officers, that measure is not welcomed universally. The responsible officers will be situated in NHS trusts and primary care trusts in England. All practising doctors will be able to relate formally to a responsible officer, who will be responsible for evaluating doctors’ fitness to practise. It is not yet clear where that role will be based. It has been suggested that in a hospital trust, the medical director might be the appropriate person to take it on. However, medical directors already have a heavy work burden and the extent of a responsible officer’s work load is unclear. That needs to be teased out in Committee.
The creation of responsible officers could give greater impetus to resolving problems locally so that they are not necessarily referred up to the GMC. However, conflicts of interest could arise if there were personality differences. Again, we must ensure that the system is seen to be fair in all cases.
I want briefly to mention the general pharmaceutical council, which is being set up to regulate pharmacists and pharmacy technicians and to inspect premises. I want to draw the Minister’s attention to a little bureaucratic overkill. The council will maintain registers of pharmacists, pharmacy technicians and pharmacy premises in Great Britain. That is fine; there is no problem with that. However, the primary care trust also maintains a provider’s list of local pharmacies, with the power to suspend or remove. It appears from the Bill that the care quality commission will require a third form of registration from individuals or companies, with the potential to intervene in the same manner as the other two regulators. That multiple registration creates potential for duplication and confusion, as well as giving rise to additional expense for health care professionals. One registration is enough. I must already pay £400 next year to stay on the pharmaceutical register, and there is debate in the profession about whether that constitutes value for money.
The hon. Member for South Cambridgeshire (Mr. Lansley) mentioned the devolution to PCTs of the global sum for pharmacy services. In theory, that is a good idea because it should enable them to determine the nature of services locally. However, the hon. Gentleman was right to say that there has been a problem with PCTs, which have not commissioned the enhanced services that the pharmacy contract envisaged. In the case of some services, such as pharmacists going into care homes to review medication, the commissioning has decreased since the contract was introduced. Primary care trusts simply do not understand pharmacy or its potential. I therefore ask the Minister whether he will ensure, if the Government are hell bent on introducing the proposal, that proper pharmaceutical expertise in practice-based commissioning is in the right place in the PCT. That will ensure that the money is best used. I make that point not for pharmacists or out of fear that the money might go to GPs instead, but so that we use all the money to patients’ best advantage.
The health in pregnancy grant—a one-off £190 —is a bit of gimmick. The Royal College of Midwives estimates the cost to be more than £120 million, and we heard a different estimate earlier. However, that assumes that there will be no baby boom. The RCM says that it supports the grant in principle, but asks for reassurance that its introduction will not be at the expense of investment in maternity services. It pointed out that the spend on maternity services fell last year by £55 million.
I felt that child measurement in the Bill was a bit of a tick-box exercise. However, when I looked into the matter, I realised that we have a golden opportunity to do some joined-up thinking. If we get it right, we will have a tool that proves useful for health professionals in identifying early obesity. The earlier we realise that a child is becoming obese, the easier it is to intervene and change the diet. I understand that height and weight will be measured. In themselves, those are fairly meaningless measurements; we should also calculate the body mass index and plot it on a graph. Measuring BMI makes it easier to spot any deviation from the norm and potential weight problems.
However, according to the press release, parents will be sent the height and weight of their child. If they have access to a computer, they can go on the website and discover their child’s BMI. That is pointless because most parents will probably not do it, not everybody has a computer and, most important, there is no tracking. It is important to track the change in BMI. Will the Minister consider the matter and ensure that an opportunity is not squandered in the Bill?
As well as the Bill’s introduction, the Department for Children, Schools and Families will publish its children’s plan in December. The plan is expected to include some thoughts on obesity. The Department of Health will also develop an obesity strategy, although the publication date is unknown, and a new child health promotion is destined for the new year. All those measures will be introduced at almost the same time, and it would be nice to have some joined-up thinking so that we can start to tackle one of the biggest public health challenges that we face.
Much in the Bill is welcome. Some details obviously need to be firmed up, but on the whole, Liberal Democrats support its broad principles.
I am pleased to take part in a debate on a complex Bill that contains many welcome aspects but also raises many questions. I shall ask my hon. Friend the Minister a few questions and I am sure that even more will be asked as the Bill progresses.
I want to speak primarily about the care quality commission but start by welcoming some other elements of the Bill. I am sure that the overwhelming majority of pregnant women will welcome £190—the health in pregnancy grant—whether it is to help them with their diet or, as the explanatory notes state, other aspects of late pregnancy, which could do with some extra money.
Surely the genuine concern is about pregnant women’s diet. All the health evidence shows that that must be tackled early in pregnancy or even before pregnancy to have an impact. All the social evidence shows that the most concern is about those on the least income—the most disadvantaged. Why, therefore, are we considering a one-off payment late in pregnancy rather than extending the healthy start scheme, or doing both?
The hon. Gentleman makes an interesting point, but he is not placing the payment in context. A woman must attend pre-natal classes and engage with doctors and health visitors. I anticipate that, when a woman becomes pregnant and goes to her doctor, she will be advised at that stage—all women are given advice about diet, exercise and looking after themselves in pregnancy—that, if she maintains her links with the health service, she will be entitled, at 29 weeks, to the valuable sum.
It is interesting that the hon. Lady seems to believe that the grant will be linked to attendance at antenatal classes. Antenatal classes in my area have been cut and cut, and there are now not enough for women to attend, so if the grant increases their availability, I shall be delighted.
The hon. Lady is generous in giving way again. She is being rather bold, as her assumption about how the Bill will work in practice goes beyond what it says. There is no requirement for a series of antenatal classes with ongoing advice about nutrition, just a requirement for a one-off meeting for general advice about maternal health.
This is exactly the sort of debate that we need to have. In order to access the grant, the woman will have to seek advice. I hope that that same woman will seek advice at an early stage in her pregnancy, as indeed most women do. They either go to the doctor to confirm that they are pregnant or go to the doctor once they have confirmed that personally. I remind the hon. Gentleman that the grant should be seen in the context of other initiatives from the Government, such as Sure Start projects and the expansion of children’s centres. Women would have to sit at home and not read a single newspaper, not watch any television and not leave their houses in order to avoid all the advice that they are now given not only about their pre-pregnancy diet and diet once they are pregnant, but about having a healthy lifestyle in general. I welcome the grant and I am sure that it will be appreciated by the overwhelming majority of pregnant women.
A second aspect of the Bill that I welcome is the removal of the liable relative rule. It is clearly unjust to require a husband or wife to pay for the cost of the care of their spouse in a care home over and above the resident’s contribution. Indeed, the overwhelming majority of local authorities do not enforce the rule, so I welcome the fact that we are going to remove it. I also welcome the new public health measures to help to prevent and control the spread of serious disease.
The extension of direct payments to those who lack capacity, by allowing payments to be made to a suitable person who will manage it on their behalf, is a welcome move, especially for families who have severely disabled children. Those children can access direct payments, which are usually made through their parents. When that child becomes 18, they cannot continue with direct payments, because they will then be an adult lacking capacity, but under the proposed extension they will be able to do so. Other groups will also be able to access direct payments for the first time, including people with dementia, people with learning disabilities and people who may have a fluctuating capacity.
Will my hon. Friend the Minister offer an assurance that vulnerable people who lack capacity will be protected? The Mental Capacity Act 2005 sets out a functional test for capacity. An individual might lack the capacity to make certain decisions, such as complex financial decisions, but might well be capable of making decisions about their personal care. In the context of direct payments, an individual with learning disabilities might not be capable of managing their finances, for example, but whoever is doing so should ask them what sort of care they want, in order to determine whether they can talk about the care that they feel they should have. Let us not think that the extension of direct payments means removing all decision making from an individual, because the same individual could, within the terms of the 2005 Act, be more than capable of making some decisions, while being incapable of making complex financial decisions.
I also welcome the transfer of the pharmaceutical global sum to PCTs. PCTs should already be working with pharmacists. Reference has been made in this debate to the new pharmacy contract. I visited my local pharmacy, near where I live in Blackpool, after the new contract was introduced. My local pharmacist had set aside an area for private discussion and consultation. He was looking forward to engaging with his customers and offering them advice. Pharmacists now have a public health role that they should be working to. The transfer of the global sum to PCTs represents an opportunity for them to work much more closely with pharmacies to deliver that important part of the Government’s public health agenda, so I welcome it.
I welcome the Government’s proposal to establish the care quality commission, in order to deliver a seamless package of care between health and social care. There are not two different groups of people, one that receives only health care and another that receives only social care. There is already a mix. Sadly, however, some people find it difficult to get a seamless progression of services through health and social care. I was at a meeting with Blackpool PCT on Friday, at which I discussed that very issue. I was pleased to hear that Blackpool PCT is already developing integrated care packages for patients, so that it can look at what an individual needs, from an ambulance to take them to hospital and the acute care that they will receive to the after care that they will need, thereby treating the individual as a whole person, not as a care episode, a health episode, then another care episode and probably another health episode after that. If by introducing the care quality commission the Bill helps PCTs to deliver that sort of integrated package of care, it will be very much welcomed.
As I mentioned in my earlier intervention on the Secretary of State, there are concerns in the social care sector that social care will be a second-level partner. It must not be, not only because of the individuals receiving that care, but equally because we cannot afford to lose the excellent work that the Commission for Social Care Inspection has done over recent years. Dame Denise Platt has offered leadership to CSCI, which has raised standards in social care, increased the profile of social care and undertaken important research. Above all, CSCI has listened to care users and their carers. I read CSCI’s annual report with interest. It is not often that I read annual reports with interest, but every hon. Member should read CSCI’s annual report, because it outlines what social care is provided, how it has changed and how it will continue to change.
I strongly believe that the hard work that CSCI has done needs to be taken forward and put at the centre of developments for the new care quality commission. My question for the Minister is: how is it going to do that? How will the new commission deal with the fact that 24,000 of the 30,000 registered health and social care providers are in social care? The new commission will be dealing on the one hand with NHS facilities and any health facilities that are large and, on the other, with a multiplicity of social care providers, the majority of which will be small independent providers in the private sector—often, small and medium-sized businesses. Bringing together the Healthcare Commission, CSCI and the Mental Health Commission in this new organisation will therefore require changes of practice to address the different forms of facility that the new body will register and inspect.
It goes beyond that, however. I am talking not only about the nature of the facilities but about the differences, which the commission will address, in policy background in health and social care. Health and social care often start from different perspectives. Heath care usually works on the precautionary principle: we see an illness, respond to it, write a prescription or perform an operation. Social care, however, has traditionally been in the risk business. It involves seeing how far someone can cope on their own, and giving them a bit of support while leaving them in their own home in the community. We are going to have to bring together those two very different ways of working, while maintaining the proper roles of the health care and social care professionals.
Interestingly, the all-party parliamentary group on social care, which I chair, is undertaking an inquiry into the changing role of the social care profession. That role is changing, but social care professionals want to hang on to what makes their role special. It will be an important job of work for the commission to ensure that it acknowledges that, and that it acknowledges the differences between health care, social care and mental health care, now that they are all within the same remit.
The commission will have to acknowledge very real differences in another area as well. The NHS is free at the point of delivery, but social care customers pay. They are at the very least assessed to see whether they should pay for most of the services that they receive, and large numbers of them do pay for day care, domiciliary care or residential care. Those paying customers will want their voices to be heard. Concern has already been expressed about how the voice of the user will be listened to by the new commission.
There is a tension between the Government’s understandable desire for light-touch regulation and the need to safeguard vulnerable individuals in health or social care. Sadly, having policies in place is sometimes not enough, because those policies are delivered by fallible individuals. Inspection to see how individuals are applying the policies that we determine is therefore vital. As I understand it, the new commission will have a less frequent inspection regime. Indeed, some social care providers might not see an inspector more than once every three years.
I listened with interest to an answer that the Secretary of State gave following an intervention on this point. He quite rightly asked why, if someone was doing their job well, we should go round and inspect them every other week. Of course we do not need to do that. However, many social care establishments have a high turnover of staff. I do not have the statistics on health care. A snapshot visit on day one might reveal an excellent care team delivering high quality services, but that does not mean that that same high quality team will still be in place a month, six months or a year later. I wonder how the new commission will be able properly to monitor the huge number of social care establishments that experience a high staff turnover. There is a particular danger involved when senior staff leave, whether the manager of an establishment or a member of the senior team. Those people set the tone for an establishment. They make sure that new staff are trained to work with vulnerable individuals. I hope that the Minister will be able to reassure me that the new commission will look at an appropriate inspection regime for that multiplicity of social care establishments.
The Bill requires the commission to establish an advisory committee to ensure that it takes into account the views, advice and information coming from people such as providers and users of social care. It should listen to the views of the public on activities within its remit. Again, my question is: how will this work? How will this be achieved in practice?
I am listening with interest to the hon. Lady, and she might be about to raise this point. It is all very well having an overarching group of the great and the good—namely, patients who are known to the system. Does she agree, however, that the benefit of the way in which CSCI has worked has been to ensure that, when an inspection takes place, local views are taken on board?
I agree with the hon. Lady. I also agree with her earlier remarks about the rights-based approach of CSCI. In my opinion, it is important that that should continue into the new commission. The rights of service users and their carers must be at the heart of the development of the new system of registration and inspection. If they are not, there is a real danger that the voices of people who are reluctant to speak up will not be heard. Patients in hospitals have access to the patient advice and liaison service— PALS—that the Government set up. Those patients are in larger establishments, with more people coming in and out and a larger group of trained staff on hand. Care homes are often small, with a small number of staff and often, sadly, very few visitors, and the people living in them can become isolated. In that context, the voice of the user of those services really must be heard.
The Bill does not include a requirement for the commission to seek the views of the public. However, two other groups mentioned in the Bill—the office of the health professions adjudicator, in clauses 100 and 101, and the council for healthcare regulatory excellence, in clause 108—are explicitly required to seek public and service user opinions. Perhaps the Government intended the advisory committee to fulfil that role. If that is the case, I would like more information on how the voice of users is to be heard.
At the risk of overusing the word “vulnerable”, I must stress that we are talking about the very vulnerable people who receive these services. I want to mention two groups in particular. Clause 44 will allow the commission to undertake special reviews and investigations. The first group that I want to mention is children with disability. My hon. Friend the Minister might recall that, last year, together with my right hon. Friend the Member for Coatbridge, Chryston and Bellshill (Mr. Clarke), we held a series of parliamentary hearings on the needs of children with disability. One issue that came out clearly from those hearings was the difficulty that many of those children and their families experienced during the transition from children’s services to adult services. I hope that the new commission will work closely with Ofsted to see how children’s services can be moved forward into adult services in the context of children with disability.
The second group involves adults with disability, especially adults with learning disabilities. Sadly, we have had too many instances of inequality of treatment of adults with disabilities, in health care and social care.
The hon. Member for Romsey referred to Cornwall Partnership NHS Trust, which was in a truly shocking state in 2005. The trust had three stars in 2004 and it had two stars in 2005. When it was awarded those stars, was anyone looking at the care on offer? When CSCI and the Healthcare Commission investigated, they described incidents such as
“staff hitting, pushing, shoving, dragging, kicking, secluding, belittling, mocking, and goading people who used the trust’s services”.
The report described a truly appalling situation.
In March this year, Mencap produced a report, “Death by indifference”, which again detailed cases of institutional discrimination within the health service against people with learning disabilities. We really must ensure that the new inspection regime looks at the quality of the care delivered; it should not be just a tick-box regime, behind which examples of unacceptable practice could be hiding.
The commission will look at how local authorities and other organisations deal with complaints, but it is sometimes by listening to complaints that we find out what is happening on the ground. I hope that the Minister will look at the commission’s role and ensure that, in reflecting on how local authorities and individual organisations deal with complaints, it will be able to build up a picture and perhaps identify systemic complaints. If the same organisation receives the same complaints time and again, there may well be something seriously wrong, and the commission needs to be able to identify that.
About 35 per cent. of people are self-funded in the social care field. They, rather than the local authority, pay for it, so they cannot bring complaints to the local government ombudsman. They have to complain to the person who runs their home. Will they make such complaints if they feel vulnerable within their establishment? If someone else complains on their behalf, how will the new commission find out about it? Again, we are talking about people in isolated settings throughout our communities. A complaints structure provides a good way of building up a profile of when things are going wrong.
Finally, I want to say a few words on the social care work force, which the all-party parliamentary group on social care is looking into. The General Social Care Council has raised with me questions about its role on the new commission. The GSCC has already registered social workers, but it is rolling out its registration regime. How will it work with the new commission to ensure that people who work in social care are registered, properly trained and have all the necessary qualities to deliver social care to vulnerable groups of people?
As a newly elected MP several years ago, I recall sitting in the Committee scrutinising the Care Standards Bill. That is one of the best Acts that the Labour Government ever introduced because it addressed the delivery of quality care. If the Bill is to succeed, we must ensure that the new care quality commission will pick up all the good points that were embodied in the Care Standards Act 2000 and ensure that vulnerable people—whether they be in a health care setting or a social care setting—are protected, listened to and supported. That will be the test against which the legislation will be judged.
I hope that the hon. Member for Blackpool, North and Fleetwood (Mrs. Humble) will forgive me if I do not follow up all the points that she has presented to the House.
I start by paying tribute to Peggy and Arthur Wynn. She wrote the first book on family policy in the 1960s. Family policy, or trying to put the family life cycle and family perspective into social and economic policy, has now become a more generally accepted idea. Some people used to think of it as population policy. That is not for us. It can apply to what might be called the private aspects of public health. One of the points that Peggy and Arthur Wynn drew to our attention was the need for pre-conception care, which cannot come from public authorities or commissions.
Whatever the benefits of having child benefit during the later stages of a pregnancy, the health of the mother can be affected when the father smokes, for example. That can affect rates of birth handicap. Some congenital malformation is perfectly normal, but some can be severe. Some of the severe ones can be affected by the state of the mother’s health and the father’s behaviour before conception. I believe that we should pay more attention to those issues. We could then add on the sort of provision that the Government are offering through the Bill. It is getting the culture right that matters.
The French, for example, decided—in the 1960s, I believe—that they wanted to deal with difficulties affecting birth and infancy, so they set out a seven-year programme with various targets that they wanted to achieve. They actually achieved the targets within a year and a half of launching the programme—long before the measures that they had introduced had any chance of having an impact. They were raising awareness and consciousness, and getting people to do more of the things that worked and fewer of the things that did not work. I hope that people will view this debate in the context of trying to get people to do things that are more consistent with what they want for themselves and for those whom they love most.
We should try to ensure that the early stages of pregnancy get the right degree of attention. I declare an interest, as a member of my family is involved in early-stage pregnancy. Having heard that the Royal Pharmaceutical Society is likely to lose its regulatory impact, I would also like to say that I am the great grandson of the last person—and for all I know, the first person—to be president of the Royal Pharmaceutical Society without being a pharmacist. But that is so far in the past—it was 100 years ago—that it is not relevant now.
On early-stage pregnancy issues, research will reveal more of what people would want to know, but we already know enough now to be able to say that once someone discovers that they have contributed to conception—this applies as much to the father-to-be as to the mother-to-be—care and concern matter. We want to get away from what could be characterised, probably falsely, as a bipolar approach to pregnancy: too many of us have our conceptions when we do not intend them, when we are very young, and too many of us delay them far too long. We need to get back to the stage of saying that creating a new child is a perfectly normal and natural thing to do and it should not have to be put off until people can afford to buy a house in their 40s—but it should not be done quite so often and so blindly by people in their teens. In effect, we want more people nowadays to make fewer of the mistakes that we ourselves made in our time.
On the regulation of the professions, I want to declare my general view that it is often easier to make an existing system work better than to have thorough reviews and a thorough all-change. That is not what we are facing. There seems to be reasonably bipartisan agreement that the preparation for the changes in regulation is worth while.
I back up what the Chairman of the Health Committee said about the civil standard of proof. This is not as big a change or contrast as people have thought. The reason why I raise the matter is that when I served on the Standards and Privileges Committee, we were considering possible offences—and certainly some actions by some of our fellow Members of Parliament—and there seemed to be a general view that the worse the implications of finding someone guilty of bad behaviour, the higher should be the standard of proof. It almost reached the stage where something could not be proved. Just because something cannot be proved, it does not mean that we cannot take action, or that by examining the matter in public at some stage, we cannot get people to understand that someone will say to them, as they would say to me, for example, if I were the person involved, “You’ve got to do better—get some retraining, or stick to the part of the job you’re good at and stay away from the part you’re not good at.” Only in very rare cases is it found that no one knew what was going wrong.
I remember some years ago being told by a GP in south London, where we then lived, that his job was to go around saying to other GPs, “Look, you can fight this out in public if you want, but I want to tell you that many of your colleagues don’t think you’re good enough at what you’re doing in this particular area. Please focus on the things that you are good at, where you’re making a great contribution.” It is not as if people have no right of appeal, or cannot ask for the matter to be examined in a rather more official fashion. It is the same sort of public service that the Whips provide in the House—in a way.
I also think that we should look for standards of proof of competence, rather than always looking for standards of proof of incompetence. Given the changes that are taking place in, for instance, medicine and sickness care, most people want to demonstrate that they are capable of doing things in a way that has been shown to be better. Obviously an innovative procedure may be challenged. I remember when, 50 or 60 years ago, the “wizard of Wigan” started to provide hip replacements. First it was said that they would not work, and then it was said that even if they did work, no one would be able to afford them. Now I have constituents who are on their fourth or fifth new hip. That is a normal development: we are used to it in many other parts of medicine, and we should allow for such innovations. Keyhole surgery, for example, became a fashion, until people discovered that in many cases it was not being done very well; now it is being done very well indeed.
I pay tribute to one of my constituents—I suppose that, for reasons of medical confidentiality, I should not name him—who worked on the campaign to save Worthing hospital. Instead of coming to lunch with me today, he had a heart attack yesterday. He was diagnosed and taken to hospital, and had his operation today, with a doctor’s balloon up an artery. He is now 100 per cent. fighting fit—or, at least, happy; it will take some time for him to recover fully. Such cases are a result of innovation and professional standards, and I pay tribute to the doctors, nurses and others who cared for my constituent. Lunch could be postponed but the operation could not, and I am glad that Worthing hospital was still there to provide it
Clause 119 has received no attention so far. Obviously Second Reading is not the time to go into great detail, but Liberty has contributed a useful thought about the provision for a magistrate to exercise major power, suggesting that except in emergencies a magistrates court, rather than just a single magistrate, should be involved. Perhaps the issue could be dealt with in Committee. When a magistrate signs a detention order—which is only one of the powers available to him—it may be challenged, although on many occasions it will be accepted. If the order is challenged, could it not be put to the magistrates court for confirmation?
Perhaps on Report, when the Committee has had a chance to consider the matter, we could have a fuller debate on whether Liberty’s point should be followed up, or at least adapted. Clearly the power to detain someone with an infectious condition or for failing to accept treatment, or for some other reason, is necessary, but I do not think that the provision should automatically be passed because of other issues of regulation. If a person’s liberty could be at issue, we ought at some stage to engage in a full and open debate on the Floor of the House—for the protection of the public, if not for that of the person concerned—and it would seem appropriate to do so on Report.
Clause 41 states that the Secretary of State must consult before making regulations. The people whom he consults will be chosen by the Secretary of State himself. That raises a point of trust. I think that whoever holds the office of Secretary of State—and it is a matter of public record that I am married to someone who once held that office—we ought to be able to trust that person and his or her advisers. We should resist the temptation to throw a few jokes around, and say that while Secretaries of State and their advisers may not necessarily be perfect, they ought to be able to run a system allowing open and genuine consultation before the laying of regulations. The public ought to be aware of the points that are made, and the Secretary of State should have to defend the decisions that are eventually made. However, I cannot claim that the system always works.
I end by paying tribute to the Health Committee. I attended its first hearing on Modernising Medical Careers and the medical training application service. The officials who gave evidence made an opening statement that allowed the tone of the meeting to be far more useful than it might have been otherwise. However, we need to know at some stage how so many people became involved, and why the outcome was—I am using very gentle language here—so inappropriate.
I want to speak about the establishment of citizens councils for the regulation of health care professionals.
Anyone who reads the Bill will recognise immediately the difficulty experienced routinely by members of the public who seek to decode important issues requiring public scrutiny and debate, and the parts relating to the long-overdue modernisation of professional regulation are no exception. It is that small yet significant part of the Bill that I want to discuss. The co-operative movement, of which I am a tiny part, is perpetually renewed in each generation when aspects of it become more relevant to current issues and dilemmas. Our task is to put it in a contemporary context, which is what I have done in early-day motion 386, tabled today, concerning the establishment of citizens councils for the regulation of health care professionals.
Co-operation and partnership working between citizens and professionals is even more essential in health care today if we are to regain the trust and confidence of the electorate and service users, and their belief that the decisions made give them the rights, dignity and patient safety that they deserve. I extend the famous Putney debate principle that
“The poorest he that is in England hath a life to live as the greatest he”
to the context of devolution, and the importance of achieving an effective United Kingdom-wide system ensuring patient safety and the best possible patient experience across the 2 million people working in the health care sector.
I do not know whether Members saw an edition of the Daily Mail, published in February 2006, whose front-page headline read “Sentenced to die by arrogance”. It reported that 18 patients had been wrongly given a breast cancer screening all-clear by a consultant radiologist, who had continued to work for 18 months before the employer launched an investigation. The case was then referred to the General Medical Council.
The allegations will sound familiar: a practitioner working in isolation, absence of monitoring of work practice, colleagues not speaking up strongly, and a health trust reluctant to intervene. The public are also familiar with recent cases in which patients have been abused and died. Failures of paediatric surgery in Bristol, and the conviction of GP Harold Shipman for murder, provoked high-profile and expensive Government-sponsored inquiries.
However, this is not just about doctors. Nurses and midwives, dentists, pharmacists and many more have their own regulatory bodies, and the Health Professions Council regulates as many as 13 professions, with more in the queue. Nor—as we have heard in today’s debate—is professional regulation concerned solely with striking people off registers and barring them from further practice. The nine statutory professional bodies are responsible for setting the standards that practitioners must meet in their education and daily practice.
We must ask ourselves what patient and public involvement can add to regulation. If regulation is to be undertaken in the public interest, it must also require public involvement. The regulation of professionals, argued Sir Ian Kennedy in his 2001 report “Learning from Bristol”, is too important to be left to the professions. He said:
“The public are entitled to be involved at all levels and stages: in both setting and agreeing the systems for assuring competence and in their operation.”
The report went on to explain why that should be so:
“First, the public can participate in the process of setting and reviewing the criteria for admission to the profession.... After all, the professional is going to be caring for the public as patients.
Secondly, public participation in this process serves as a warranty that the public's interests are being safeguarded and as a reminder that the profession exists for the public”.
In 1999, the National Consumer Council took an outsider’s look at professional regulation, questioning whether it was fit for the fundamental purpose of protecting the public. It found a confusing patchwork of procedures, terminology and standards for the different professions, and pronounced the system to be out of touch with the times. The Bill gives us a once-in-a-generation opportunity to modernise professional health care regulation for the benefit of future generations.
The challenges that patient and public groups have raised about the direction of change—system complexity, the lack of transparency and clarity in processes, and the failure to join up complaints and redress systems—remain with us, and measures in the Bill are intended to address those issues. However, the modernisation of professional health care regulation requires a much more dynamic approach to public and patient engagement than is set out in paragraphs 1.11 to 1.27 of “Trust, Assurance and Safety—The Regulation of Health Professionals in the 21st Century” and in the Bill.
The general public do not necessarily know much about regulation, but they assume wrongly—and fondly, perhaps—that there are robust systems for ensuring that practitioners are competent and up to date. That is a reasonable expectation, which Government must ensure is met. In 2005, the Department of Health commissioned a research study from MORI to examine the attitudes of the general public and doctors towards medical regulation and assessment. The key findings of the research are worth highlighting. It was found that few members of the general public know anything about the current system of assessment of doctors after qualification. Almost half of the sample of the general public assume that regular assessments are already taking place, with more than one in five thinking they already happen annually.
There is widespread support for regular assessment among both the general public and doctors. Nine in 10 members of the public and more than seven in 10 doctors thought it important that doctors’ competence be assessed every few years. Nearly half of the public thought that those assessments should be done on an annual basis, while doctors favoured doing it less frequently; interestingly however, hospital doctors seem to favour more frequent assessments than their colleagues in general practice.
The current system of medical regulation is not visible to the general public. It is striking that many people believe that regular assessment of doctors is already taking place. Moreover, almost all wished it to take place frequently, and half said that there should be annual checks. That public view is in marked contrast to that of commentators and politicians, who often hold that regulation should be a “light-touch” process—a view not necessarily shared by patients in the United Kingdom.
Changing traditional professional attitudes requires an informed public, who have an important part to play in co-producing public safety and improving the overall patient experience. That cannot be effectively achieved by the separate PPI—patient and public involvement—arrangements financed by different regulators within the health care team. I hope that the Minister will respond to the fact that the Bill proposes that lay membership of the Council for Healthcare Regulatory Excellence be reduced from 10 to seven people and be appointed to “reflect”—whatever that might mean—rather than to represent, an increasingly diverse public.
The CHRE, which is in practice more accountable to Government than to Parliament, would in my view greatly benefit from independent citizens councils that are representative of, and accountable to, diverse community interests in each part of the UK. I have today tabled early-day motion 386 because we need to recognise the difficulties that patient and public groups face in finding the resources to engage in detail with the complex and intricate processes of balancing professional and public interests. New citizens councils should be established in each of the four countries of the UK to work alongside the CHRE. The essence of democracy is that it makes it possible—I emphasise the word “possible”—for a diverse public and patient view to express itself.
The citizens council idea is not new. As specified in the English NHS plan in 2000, the National Institute for Health and Clinical Excellence has valued its citizens’ council and has referred to it in positive terms on numerous occasions. There is learning to be had and examples of how it might work in the many citizens juries that have met, and in the national debates that have been conducted in fields such as health, environmental issues, urban planning and genetically modified foods. In the context of health care professional regulation, citizens councils should be independent—and should be seen to be independent—and should be funded from the public purse, in order to explain to, and inform, interested and diverse patient and public groups about the nature and significance of proposed changes to the system of professional health care regulation, carry out consultations and collate responses on a four-country-wide basis.
I stress the importance of lifting this debate out of the technical language in which the dialogue is currently conducted. We should give a real chance for a public perspective to be heard and taken into account, alongside that of the very well-organised and well-financed professions that are constantly lobbying and fully engaged in promoting substantial legislative change, both in terms of this Bill and, as my right hon. Friend the Member for Rother Valley (Mr. Barron) mentioned, through section 60 orders under the Health Act 1999. I believe that one has been tabled today.
Let me finally turn to the subject of health care support workers. There is concern that pressing issues for patients and the public—such as the effective regulation of those who give hands-on care to vulnerable population groups in hospitals, nursing and residential homes and in the community, often involving intimate and personal care in health-care assistant roles—are not being treated with the urgency that they deserve, although such workers are increasingly important in the context of community-based provision.
Those concerns include the lack of education and training for tasks traditionally carried out by qualified, registered health care professionals and the lack of a regulatory framework for health care support workers. Responsibility and accountability for their actions in clinical and other settings cannot continue to be considered behind closed doors, and active public engagement is required. Citizens councils provide the mechanism to make this a reality. I hope that the Minister will respond specifically to that point.
There is common ground among the main political parties; I hear that there is unlikely to be a Division tonight. We are all seeking to find ways of securing democratic renewal and engaging citizens in hard decisions, addressing risks, balancing rights and deciding on priorities for Government action at UK and devolved levels. Although they are invisible to the public—we must ask why—professional health care regulation and the regulation of health care support workers are key areas in which it could be demonstrated that bodies such as citizens councils can work and make a difference. However, the Government also need, jointly, to put in place a structured system, which is inclusive and ensures that a wider perspective is brought to the debate, alongside the CHRE’s inevitably close working relationship with professional health care regulatory bodies.
The Minister needs no sympathy from me, but it is true that Ministers have an unenviable task in this respect. They have to cope with the intricacies of separate legislation and the complexity of a UK-wide system. They will face—they are already facing—strong professional lobbying, and objections to ending elected member representation will undoubtedly be one theme. Another theme has been the standard of proof in fitness to practise proceedings under part 2 of the Bill. At its heart, however, the issue they face is very simple. The public expectation of health professional regulation is that it will deliver health professionals who can be trusted to provide up-to-date relevant treatment and therapies, who are dedicated to developing their knowledge base, and who have patient safety as their overriding objective.
When things go wrong, people expect a full explanation, and perhaps recompense, but more often changes that will reassure them that the situation is unlikely to occur again. Root-and-branch reform was the demand from some of the patient-focused organisations that responded to the White Paper consultation. The MORI polls that I mentioned earlier showed that people assume that regular checks on health professionals are already in place, and that policy is much further along that road than it actually is. Failure to take decisive action now threatens to destroy public confidence, not only in regulation, but also in the policy process itself.
In summary, public engagement can help drive the co-production of modernised professional health care regulation, especially in relation to secondary legislation, in the period to 2011. I urge the Minister to take on board my comments, and I hope that the Government will introduce citizens councils, so as independently to inform the CHRE’s strategic decision making and strengthen a four-country approach to patient safety and improvement of the overall patient—or service-user—experience.
It has been a privilege to attend the debate. There have been numerous thoughtful contributions from experienced and knowledgeable Members, and it is a pleasure to follow them.
As suggested by my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) in his response to the Secretary of State’s address, one could have been forgiven for thinking that the first health Bill under a new Labour Prime Minister would be a bold attempt to set a groundbreaking agenda for the health service—that most iconic yet troubled of our public services. In recent months, we have heard some expansive, and at times not unattractive, rhetoric from Health Ministers about tackling health inequalities and the importance of the public health agenda, but I am afraid that the measures in the Bill do not back up that rhetoric and provide little confidence to suggest that the Prime Minister and his Ministers have a serious and compelling long-term vision for our health services.
There is considerable agreement in all parts of the House on the Bill’s broad policy objectives, but I want to address an issue on which there is room for some contention—indeed, it has been commented on already today—the health in pregnancy grant. The notion that pregnant mothers might need assistance in making choices about their diet and lifestyle in order to give their babies the very best start in life is absolutely unobjectionable. In an age of increasing obesity, and yet a wider and deeper knowledge about the importance of good diet in pregnancy, no one would disagree with recognising that the state can play a positive role in supporting pregnant women and helping them to eat the very best food. It is, Mr. Deputy Speaker, literally motherhood and apple pie.
However, it is a huge leap from that position to supporting a one-off cash payment being made to all mothers, regardless of socio-economic background or geographical location—there are differences in health outcomes and diet that are related to the geography of the UK—at a fairly late stage in their pregnancy. It is a huge leap from endorsing the general principle of supporting pregnant women in making healthy lifestyle choices, to supporting a one-off cash payment at a late stage.
I understand the hon. Gentleman’s reservations about the late payment of a one-off grant, but can he come up with a scheme that would work better and really get to all such women, regardless of their circumstances, and not just those who apply for a grant, in order to ensure the widest possible uptake?
I will go into this issue in a little more detail shortly, but where is the evidence to suggest that absolutely all women need assistance from the state in making good choices about their diet and lifestyle in pregnancy? Surely the priority should be targeting limited resources on those in most need. The evidence to suggest that such a crude, untargeted payment after the 25th week of pregnancy will lead to better dietary choices on the part of mothers, and therefore to better health outcomes for babies, is simply non-existent.
We can look at conditionality, and at alternatives to how this money might be spent that achieve similar outcomes. Where are the results of the pilot and the pathfinder studies to back up these policy proposals? Were any lessons drawn from international experience to suggest that such a one-off lump sum payment can deliver the policy objectives that we want to see?
I am not disagreeing with that—there is no doubt that the cash will get to people. My argument concerns how the cash will be used and whether it will actually deliver the health outcomes that Ministers are saying it will.
I turn to the timing issue and why there is this focus on such a late stage of pregnancy—the 25th week. That approach conflicts with a lot of expert opinion and practical wisdom out there regarding ensuring the well-being of a pregnant woman for the whole term of her pregnancy. Tam Fry, director of the Child Growth Foundation, was quoted in The Observer when this policy was announced as saying:
“By the time a woman falls pregnant, she already needs to be eating well”.
Daghni Rajasingam, speaking on behalf of the Royal College of Obstetricians and Gynaecologists, said at the time:
“If a woman is not already eating a healthy diet by that stage”—
the 25th week—
“then encouraging them to eat more fruit and vegetables”
from 25 weeks
“is too late...Even for small babies it is too late, there is very little you can do to increase growth at that stage.”
So the emphasis on the 25th week is entirely misplaced. The Government should be stressing the need for pregnant women to learn good lifestyle and well-being habits and to unlearn some bad habits, such as those related to smoking and alcohol, at the earlier stages of pregnancy.
I do not remember much of my National Childbirth Trust classes before my first child was born, but I do remember two things. I remember the women being separated from the boyfriends and husbands at the very first meeting, and the men being put to one side and given a game to play. We were given a diagram of a female body and about 25 labels, and we were asked whether, as a group, we could label a woman’s body correctly. I think that we scored under 75 per cent., which suggests that men should tread carefully when talking about such issues. I also remember the emphasis that was put at the very outset of those classes on the importance of diet and good lifestyle. There was no discussion of the 25th week and of getting one’s act together at a late stage of pregnancy; the focus was always on sorting out the issues—giving up smoking, cutting down on alcohol, watching what one eats and eating good quantities of fruit and vegetables each week—from the very start. So the focus on 25 weeks is misplaced.
I want in a very gentle way to raise with the Minister a question that is not purely hypothetical. There is some discussion in all parts of the House of the termination of pregnancies at this time, and whether there is a need to look again at the upper-term limit and to reduce it. What would happen if, the two Houses in this Parliament being willing, the upper-term limit were reduced to, say, 22 weeks? Would there be a need, therefore, to move the timing of the cash payment back, in line with that? If not, in theory a pregnant woman could legally make a claim for the grant and also legally terminate a pregnancy. I am talking very hypothetically, but I would welcome a response from the Minister because termination limits is a live discussion.
The hon. Member for Blackpool, North and Fleetwood (Mrs. Humble) spoke about the meeting with a health professional that a pregnant woman would need to have in order to claim this grant. I share her vision of how that would work in practice. She talked about an ongoing dialogue involving giving advice to pregnant women about diet and lifestyle choices, for example. However and as I said in an intervention, the Bill, which is vague on detail, does not provide for that. Rather, it refers to a woman receiving
“advice on matters relating to maternal health from a health professional”.
She will have had that, anyway, from her health visitor or GP, so I do not see how we get from the Bill to the idea put forward by the hon. Lady, which I support, of an ongoing interface between the pregnant woman and a medical professional about diet and healthy choices.
I turn to how the scheme will be administered. We know that it will be delivered through Her Majesty’s Revenue and Customs—this huge, sprawling, merged Department that, as we now know, is beset with operational difficulties. If we did not need any other reminders, the events of last week have shown that yet again. However, there is another experience involving HMRC that is relevant here—that of tax credits. We all know from our constituency surgeries the number of people who are having to pay back money that the Treasury is clawing back as a result of overpayments. We know that when many people are given up-front payments, they spend them—that is in the nature of things. Those on low incomes or facing pressing expenditure needs, in particular, will spend them. Where is the evidence to suggest that a pregnant woman will use this one-off cash payment of the health in pregnancy grant in a planned way to meet their ongoing dietary needs and to ensure that they can pay for good-quality fresh fruit and vegetables? Will not human instinct take over if this money is paid in a one-off lump sum? The Secretary of State has talked outside this Chamber about the “broccoli police”, who will not be coming round to check that all the money is being spent on what it is intended for. However, it is worth asking whether this money will just get burned up very quickly and will not be used in the way that Ministers intended.
To conclude on this point, the Government are proposing to spend a significant sum—£120 million—and if one accepts the line from the Royal College of Midwives, that figure will increase significantly in the years to come. In the absence of any effective strategy for well-being during pregnancy or any prioritisation in respect of poorer women or women from areas where there is a higher incidence of diet-related problems, and when the maternity services of many communities are being eroded, could the money be put to better use? To my eyes, this is more part of a political strategy than a health one, and to many people it smacks of the Government trying to create a new tier and category of cash-receiving clients of central Government. There is room for contention and vigorous debate on this measure.
On the national child measurement programme, the hon. Member for Caernarfon (Hywel Williams) knows that I am not the greatest devolutionist in this place, but I support the measures in the Bill to extend powers to Ministers in the National Assembly for Wales to introduce a similar scheme in Wales to the one that has been running in England and to bring it in line with the changes that will be introduced in England for measuring the height and weight of children with a view to feeding the information into body mass index calculations.
Wales has a significant and growing problem of childhood obesity. It is not a new phenomenon. Ten years ago, groups of general practitioners in Wales were warning that an epidemic of childhood obesity was about to hit Wales. In the past eight years, since the establishment of the National Assembly for Wales, which has responsibility for these issues, precious little substantive action has been taken to tackle childhood obesity in Wales. I welcome this measure in the Bill. If it enables, and provides more tools to, Health Ministers in the Assembly to tackle childhood obesity, it has my support.
I was excited to see the small section on social enterprise in the Bill. Some years before being elected to this place, I was involved in setting up a social enterprise in south London. It was attached to a large mental health charity working with people from the African and Caribbean communities. The idea was to create a social enterprise using some of this charity’s clients in producing high quality frozen African and Caribbean food to sell to national health service primary care trusts, which were demanding such food as they moved towards having more ethnic choice in the meals that they provided. We faced huge hurdles in setting up the social enterprise. Trying to do business with PCTs, get contracts and negotiate all the different hurdles that we had to clear was a time-consuming and expensive process. We benefited from the fact that a PCT supported what we were trying to do, shared the vision of the social enterprise and put its resources behind it.
If, as I understand it, the measures in the Bill will extend such provision, give more direction to it and enable far more social enterprises to crop up in the health and social care field, that can only be a good thing, because this is a rich environment for social enterprises. It would be good to hear from Ministers about their vision for social enterprise and how it can contribute to health and social care.
As the House well knows, I still do some general practice for the national health service and I have a particular interest in public health. As we have heard this afternoon, one of the most serious public health issues facing this country is obesity, which is not only growing at an extraordinary and alarming rate, but is one of the most difficult areas to tackle.
The Foresight report, published on 17 October, set out some alarming statistics, and I want to focus on the part of the Bill that deals with the weighing and measuring of children. The report said that in 2004 approximately 10 per cent. of boys and girls aged six to 10 were obese, but the forecasts were rather more alarming. The report pointed out that those figures are likely to increase to 21 per cent. for boys and 14 per cent. for girls by 2025, and to 35 per cent. for boys and 20 per cent. for girls by 2050. Those figures are probably conservative, because they are based on an international standard for measuring obesity that we do not use in this country and which, if anything, underestimates the prevalence of the problem.
The national child measurement programme records the height and weight of children in reception and in year 6, and at least gives us some information to go on. The national public health service was recently asked by Government to undertake a feasibility study in 2007-08 on the creation of a national surveillance programme of children’s height and weight. Again, that goes some way towards addressing things. The provision in the Bill for weighing and measuring children is buried in the miscellaneous provisions in part 5. I call on the Government to go much further, both from the health point of view and in ensuring much more cross-departmental work in government to try to tackle this issue.
There is no question but that the provision of better information and advice to parents about their children’s health is essential. The majority of parents probably are well aware of the growing incidence of obesity and the need to tackle it, but parents do not always identify problems with their own children. As a general practitioner, I frequently see parents who either are not aware that their children are obese or have little idea how to tackle the situation. It is alarming to note that some parents still say that their children have puppy fat, that they will grow out of it because it is just a phase, that it is because of the hormones or that it will be okay. Unfortunately, that is not the case, and more often than not obese children become obese adults.
Without question better surveillance is needed, but that will take us only so far. Although as individuals we are responsible for our bodies and our health, our freedom to act is often constrained by the nature of our built environment. That is why I want work to be done much more closely with other Departments and across government. Not only our built environment, but our income, our access to transport, the nature of local retail markets and a myriad our social and economic circumstances all come to bear on this issue.
A parent may be fully aware that their child is at risk of becoming obese and they may be fully committed to preventing that from happening or to tackling it, but if they live in a house that is separated from the nearest park by a busy road, or they are reliant on local convenience stores that sell energy-rich food but do not necessarily sell much fresh food, their ability to sort out their child’s obesity problem is limited.
As a consequence, the state, as Lord Krebs made clear in his excellent foreword to the recent Nuffield Council on Bioethics report on public health, has an ethical responsibility to intervene and remove the constraints limiting one’s ability to live a healthy life. In that sense, state intervention should be seen as a means of empowering individuals and of maximising their freedom to live a healthy life rather than, as some critics tend to say, as an unwarranted state interference in people’s lives.
What form of intervention should the state undertake? The Government need to consider a range of supply side issues. Educating children about healthy eating and healthy living in school together with infrastructural measures aimed at enabling people to undertake more physical activity are obvious supply side factors. Other, more contentious interventions, such as a complete ban on the advertising of food and drink products that are high in salt, fat and sugar during TV programmes are justifiable. A complete ban will give children—the most vulnerable members of society—the freedom to make informed choices for themselves based on information on healthy living that they receive from schools rather than on undue influence from food and drink manufacturers.
Providing people with the opportunity to develop the necessary life skills and the right resources to live healthily is not necessarily enough in itself to deliver a meaningful reduction in overall obesity levels. People often have the necessary motivation to live healthily and possess the necessary skills to do so, but unless they live or work in an environment where there is an established culture of living healthily, there is a good chance that they will never be able to reach their goals. If a community is dominated by people in full-time employment who drive to work each day at 8 am and close their front door when they return home at 6 pm, as happens in many communities, simply providing better sporting facilities and more opportunities will not be enough to change people’s habits. The chances are that if our family, friends, neighbours and peers do not exercise, we will not either.
What can we do about that? In order to achieve a paradigm shift in society, public health policymakers around the world are increasingly experimenting with social marketing strategies aimed first at marginalising antisocial, unhealthy behaviour and secondly at embedding healthy behaviour in the fabric of people’s everyday lives. They would argue that until an activity becomes a normative behaviour and is firmly entrenched in people’s lives, so much so that they do it as a matter of course, we cannot judge a policy intervention to be a success.
Smoking is a prime example of that. Whereas once it was seen as an unremarkable practice, or occasionally even as a socially desirable one, in many public areas smoking is now a marginalised activity—in public spaces it is illegal. We need to take a similar approach on physical activity. That is particularly important at school level where for a child to be seen as fitting in and making sure that they do not miss out on something is of paramount importance to their sense of well-being.
We have to turn that herd instinct to our advantage. Instead of its being socially desirable to be driven to school and socially undesirable or abnormal to walk, we have to try to turn that perception on its head. It is perfectly possible, for instance, to imagine children insisting that they be allowed to join the walking bus to school because that is where all their friends are and where all the social intercourse takes place. Children who are driven to school could feel that they are missing out on an essential part of their upbringing. If we can change the children’s perception in that way, we will see a genuine shift in behaviour. If that becomes a normal way to travel to school, parents will also be less concerned about the obvious potential dangers of walking.
I can see similar examples all over my constituency. People are social beings. We follow the crowd. We ignore empty restaurants and go to full ones. We do not sit down on an empty bench in an empty park because that looks odd, so instead we go to busy parks and sit on benches where other people are sitting. Huge amounts have been spent to create new public spaces in my constituency, but little thought has been given to how they will be used. It is pointless to create them if they do not deliver. Concerns about security, blind spots, lighting and the possible presence of antisocial users mean that normal people tend to avoid such spaces—except on special occasions when an organised event takes place.
The problem is that when we plan and construct our built environment and leisure spaces, we do not think enough about how—or indeed whether—they will be used by the people they have been created for. Or alternatively, we make assumptions about how they will be used without actually going to the trouble of asking potential users what they want. In many cases, that is because of time and cost issues. A developer will often choose an off-the-peg design because it is the easiest thing to do, and keep stakeholder consultation to a bare minimum, because that can also be difficult. Involving the local planning authority also saves time and avoids expense.
Because bad design is so rarely challenged—and almost never on public health grounds—highly questionable design principles that have never been properly tested become established design conventions that continue to be followed by planners, developers and designers, because that is the way that things have always been done. Consequently, the majority of new developments that are built in this country contain vast areas of unused, unloved, badly planned, dead public space. Only the roads are used regularly. The cumulative cost of those mistakes in social, economic and health terms is colossal. We can and must do something about that.
In many cases it will mean sweeping our established design principles off the table and engaging with users at the very start of the design process, rather than seeing the consultation process as merely a tick-box exercise. Public health professionals also need to be engaged in a meaningful way from the start, rather than simply being invited to comment on established plans. That is blue-sky thinking and it will certainly be more expensive, but if it helps to produce a happier, healthier, more active and socially engaged community in the long term, the savings will more than outweigh the initial costs. I hope that during the Bill’s passage we will be able to envisage, and possible even enshrine in the legislation, how cross-departmental government could deliver some of those aims.
Another issue in which I have an interest, as chair of the all-party parliamentary pharmacy group, is pharmaceutical services. The hon. Member for Romsey (Sandra Gidley) has already laid out some of the concerns of some pharmacists about the change in regulations, and I echo what she said.
I wish to help the hon. Gentleman out. He rightly declared his interest as a practising medical practitioner at the outset of his speech, but before he addresses the issue of pharmacy, he might wish to remind the House of his entry on the Register of Members’ Interests concerning overseas visits.
I certainly refer anyone who is interested to the register. I have been on pharmacy-funded trips in the past to take part in international debates and they are registered fully.
There are concerns about the global sum being transferred straight to PCT budgets. Although the Pharmaceutical Services Negotiating Committee has welcomed the creation of a single funding stream as a means of simplifying funding arrangements, many pharmacists and pharmacy organisations have one or two concerns. Those include whether in times of financial difficulty the PCT might be able to move money away from pharmacy services to other services if it felt that that was necessary. That would be regrettable and, with pharmacists doing more and more clinical work—and being asked to engage more in front-line clinical services—there should be some way to ensure that money given to PCTs through the global sum is protected to ensure that it does not happen.
The hon. Lady also mentioned the new regulatory procedures. The Royal Pharmaceutical Society wants confirmation that the transition to a new regulator will be managed properly, will be adequately funded and will utilise the unrivalled experience of many individuals and organisations that play an important role in pharmacy. I ask the Minister to ensure that the process includes full consultation with the profession and all stakeholders in pharmacy.
I am pleased to follow the hon. Member for Dartford (Dr. Stoate), who is the only practising member of the medical profession in the House. I congratulate him on his speed of delivery, which means that he gets through a vast amount in a short time, which is very welcome. I cannot promise to go as fast, but I shall not take much longer.
I shall confine my remarks to parts 1 and 5 of the Bill. I shall not touch on the public health issues in part 3, because they are widely welcomed, nor on the regulation of the professions in part 2, because it has been widely covered and some of my concerns raised. Even though I am retired, I am still perhaps a little too close to the profession to avoid being accused of partisanship.
Part 1 relates to regulation of health care organisations and the formation of the care quality commission. I have long been in favour of bringing together health care, social care and mental health care, so that is a welcome move. However, I have several worries. The first is that it is a huge task for one organisation to undertake. I am worried about the financial backing, the personnel and whether the resources will be available to make the body fully efficient. Secondly, the Bill is short on listing the actual duties of the new commission. The Picker Institute has produced a valuable briefing on the Bill, which states:
“The Picker Institute believes the principal duty of the regulator should be to promote the interests of patients, service users and the public with regard to the quality and safety of care services.”
That is vital. The Secretary of State used the words “safety” and “quality of care” in his introduction, and the commission must satisfy those requirements.
I am also concerned about patient and public involvement. The Picker Institute suggests a user panel. The hon. Member for North-West Leicestershire (David Taylor) mentioned a citizens council and the hon. Member for South Cambridgeshire (Mr. Lansley) was worried about the lack of a formal structure for patient and public involvement. Why is there no mention in the Bill of Local Involvement Networks—LINks—the organisation designed by the Government to take over from the community health councils and the patient forums that they abolished? LINks is the one body made up of ordinary individuals, patients and citizens that can translate their feelings to a regulating body. LINks should be at the heart of assessments of the quality and safety of care. It represents patients, and the NHS belongs to patients, so it is inexplicable that LINks is not mentioned in the Bill—I may have missed it, although I looked carefully.
The simple reason is that LINks is already established under previous legislation. I am happy to talk about it at great length, but it is not required to be covered in the Bill.
I thank the Minister for that intervention, but although we do not need to establish LINks, there should have been some acknowledgement in the Bill of its presence and importance.
LINks is in trouble over TUPE—the Transfer of Undertakings (Protection of Employment) Regulations 1981. It is not yet clear whether TUPE applies to staff in the Commission for Patient and Public Involvement in Health, who badly need to know about that issue before the commission is abolished. A letter to the Department of Health from the CPPIH asks two crucial questions, which I press the Minister to answer; even if he cannot not do so now, he should do so fairly soon, because the matter is urgent. The commission asks the Department to
“Provide its opinion on whether TUPE is likely to apply”
“Give explicit instruction to the CPPIH regarding the risks associated with TUPE and current redundancy plans”.
If those points are not clarified by the time the commission is abolished it may run up a huge bill that it will be unable to pay.
My final point about part 1 relates to the Healthcare Commission and problems with the NHS complaints procedure that have been mentioned by other Members. The complaints process must be independent and fair, but with the removal of the commission from it we shall lose the automatic involvement of independent experts. In a complaint, especially where there are clinical problems, the involvement of knowledgeable, independent clinical specialists is essential.
The hon. Gentleman makes a powerful point about something that, as he knows, goes back a full eight years to the appalling loss of community health councils when they were summarily axed in England. CHCs were the one place where a complainant could be confident that there was an independent person to hold their hand and help them. That independence was important, as he says.
I thank the hon. Gentleman for that intervention. Independence is crucial. That obligatory independence will be lost in the complaints process that will result from the removal of the Healthcare Commission. It will be left to people in an internal complaints process to decide whether to include an independent view. Will they want to do so? Of course not. That is a huge weakness in the proposals. The hon. Member for Pendle (Mr. Prentice) pointed out that there would be a tremendous increase in the number of cases taken to the ombudsman. In a briefing, Age Concern noted that there could be a massive increase in the ombudsman’s load if the proposals go ahead. I strongly press the Minister to write some independence into the proposed complaints procedure.
My final points relate to part 5. What may for me be the most important clause in the Bill has not yet been mentioned: clause 129, “Duty of Primary Care Trusts”, which deals with the arrangements for improving the quality of health care. It reveals that for the last six years, since I have been a Member, I have been taking entirely the wrong approach to complaints. I have been tackling providers about the service that they provide, but clause 129 indicates that I should have been tackling the commissioners because they have the right to remove the service.
In the Queen’s Speech debate on health, I described some of the appalling things that were happening in my patch and in others. Not long ago, I had a meeting with the chief executive and the chair of our primary care trust and I was encouraged. Even at that stage, the chair had received many complaints about the quality of care and was beginning to realise that it was the duty of the PCT as commissioner to point out the problems and try to get them rectified. I am pleased that clause 129 is in the Bill; it is short but it must not be lost, because it is crucial.
Clauses 132 and 133 relate to the weighing and measuring of children in England and Wales. Obesity in children has been mentioned by the hon. Member for Dartford, at length, and by the hon. Member for Romsey (Sandra Gidley). The Select Committee on Health held an inquiry into obesity in 2003-04. Recommendation 45 stated:
“We recommend that throughout their time at school, children should have their Body Mass Index measured annually at school, perhaps by the school nurse, a health visitor, or other appropriate health professional. The results should be sent home in confidence to their parents, together with, where appropriate, advice on lifestyle, follow-up.”
At the time, we were slightly attacked as it was thought our proposals would stigmatise obese children. I did not think that argument had any force at all because there was evidence that parents were unaware that their children had a problem.
The importance of public health issues, especially obesity, has been recognised for a long time. Public health came to the fore in the 1880s with the great recognition that bacteria caused disease. As time is not at an absolute premium, I should like to remind the House of Sir Walter Scott’s words in the novel “The Surgeon’s Daughter”, published in the 1820s. He bemoaned the poor recompense for a Scottish village doctor compared with his English counterpart:
“The burgesses of a Scottish borough are rendered by their limited means of luxury, inaccessible to gout, surfeits and all the comfortable chronic diseases which are attendant on wealth and indolence.
There the mothers of the state never make a point of pouring, in the course of every revolving year, a certain quantity of doctors’ stuff through the bowels of their beloved children.”
As long ago as 1820, the problems of idleness and affluence were recognised. I do not say that we should return to poverty, but I welcome the Bill’s emphasis on public health, especially the measures aimed at spotting overweight children—not to stigmatise them, but to tackle the problem.
I am grateful to be called to speak in this incredibly well attended debate.
When I heard that there was to be a debate on health I had intended to talk about my constituency, to tell the House that it is important that Cheshunt gets an urgent care centre when the PCT reports back in a couple of weeks’ time. I had planned to tell the House what a wonderful job my council has done in supporting health service infrastructure in Broxbourne—and long may that continue. However, I am not going to do that, because it has absolutely nothing to do with the Bill. It would be totally gratuitous of me to use this opportunity to get those things off my chest.
I would particularly like to focus on the work of the care quality commission. In my constituency, there is a growing loss of confidence in the NHS and in hospital care among sections of the people whom I represent. The NHS still provides high levels of service to the vast majority of patients, but over the past few years there has been an increase in hospital-borne and hospital-acquired infections. That is causing unease, and it is causing some to be fearful of being admitted to hospital. It is important to address those fears, because hospital is a place where people should go to get well. It is a place that puts people back on their feet, but if well-meaning people start to fear going to hospital, that will undermine confidence in the NHS, which will be to the detriment of us all.
Over the past few years, there have been a number of well-publicised—I will not call them disasters—very unfortunate events that have led to people dying unnecessarily. They occurred at Tameside in Manchester, and there have been problems with C. difficile at Stoke Mandeville, and most recently at Maidstone. I am trying to understand how we in this country have got to the position in which people die in hospital from diseases that are preventable. I admit that some bugs are developing resistance to antibiotics and other treatments, but the idea that people go to hospital and fall ill and die from disease is extremely worrying. I am trying to understand why the growth in the number of such illnesses has occurred over the past few years. The issue is important in the context of the care quality commission and its work in trying to identify the problem, disassemble it and then come up with solutions that actually work.
When I am canvassing in my constituency, I talk to a lot of people who work at Chase Farm hospital. As you may know, Mr. Deputy Speaker, the hospital faces a fairly rocky and uncertain future and I am met on the doorstep by nurses and orderlies who are often in tears when I speak to them about what is going on in their hospital and its future. They tell me about low morale, that people do not know whether they will have a job in a year’s time and that it is difficult to recruit. They tell me about a lack of pride in the place, which is very worrying when set next to the fact that Chase Farm hospital has battled for many years against diseases such as MRSA. It is fighting bravely to remove them, but it would be much easier for the hospital to get to grips with such diseases if there was a sense of common and shared purpose among the staff. When the care quality commission considers hospital-borne infections and how standards could be improved, it cannot put to one side the fact that the morale in the hospital with which it is dealing is a contributory factor.
One example of where I think the NHS is making mistakes relates to the subject of nurse morale. I was talking to a nurse who had finished her shift for the day and was getting ready to leave. She noticed that an elderly lady in one of the wards had not been fed that evening. Being a conscientious nurse and a human being, she decided to stay on and feed her. The nurse knew that if she left, those on the incoming shift would not take it upon themselves to feed that elderly woman. The window of opportunity would have been lost, so the nurse stayed back in her own time and made sure that that elderly person had supper and nutrition. That is important, because we know that a number of elderly people in care do not receive proper nutrition. Indeed, some are starved to near death.
The nurse fed the elderly lady, got into her car and travelled 25 miles home. When she got home, she listened to her messages, including one from a hospital manager saying, “Please come back to the hospital, because you have not finished your paperwork.” The nurse knows full well that such a message would not have been left if the elderly patient had gone unfed. If the nurse had done the paperwork, not fed the patient and gone home, nobody would have cared and that telephone call would not have been made. She has now left the NHS, which is a great loss to us all.
The care quality commission must not allow people to get off the hook of accountability. Too often in these debates, a smokescreen is thrown up about who is in charge and about contract cleaners. My view is that the chief executives are in charge of their hospitals and they have to take ultimate responsibility for their being well run. I know that chief executives work under very difficult conditions. They have targets imposed on them and they have to meet benchmarks and work extremely hard to keep Whitehall happy. However, that is no excuse, and it must never be an excuse, for allowing people to lie in their own faeces, to lie in their own vomit, to go unfed and not to be cared for. That is an abrogation of responsibility on the part of those chief executives.
Chief executives are paid considerable sums of money. Some earn well over £200,000, and with large sums of money come huge levels of responsibility. Too often, I feel that chief executives think that they are running a hospital well if they are sitting in their ivory tower surveying all those they command. I am not going to compare running a hospital with running a business; the two are very different. However, I will make the following comparison. Some successful people running enormous businesses make sure that they spend at least one day a week out in the business making sure that they know what the customer experience is like and that their customers are getting what they want. We need some more of that in the NHS. We should have strong management teams in the NHS that allow chief executives to get out of their ivory tower and their offices and to spend time on the shop floor.
That is possible under the existing regime. The new chief executive at Winchester hospital makes sure that he eats hospital food under an assumed patient name once a week. He does a lot of things to be on the wards to see what is going on and carries out cleanliness inspections. Some would say that he should not have to do that, but that approach seems to be delivering results and more could learn from that lesson.
The hon. Lady has made an important point. Some say that that should not be the case; I say that it absolutely should be the case. We need to see chief executives on the wards.
Before the hon. Lady helpfully intervened, I was about to say that I was amazed when we were shown pictures of Maidstone hospital and saw the filth and the squalor that were allowed to go unaddressed. Any serious senior manager worth their salt would have dealt with that. What we saw was disgraceful. As I have said, with responsibility comes leadership and we need leadership in the NHS.
Ideally, I hope that the care quality commission will be a passing phenomenon. I hope that we have it for five or six years, but that there will then be chief executives of sufficient quality to mean that it is accepted that hospitals are of such a uniformly high standard that we do not need to burden them with more regulation and more inspection. Until that time is reached, I very much see the need for the commission.
In my final couple of minutes, I wish to deal with the issue of obesity and the weighing and measuring of children at school. Obesity is a huge problem. Short of people just closing their mouths and not eating, it is very difficult to address. I do not mean that flippantly because, in particular, we need to address the problem of obesity in children. Obesity in childhood can have an impact on a person’s health outcomes throughout their life and place additional costs on the NHS. Perhaps the Minister can explain matters further either here or in Committee, if I am lucky enough to serve on it—that is not a hint, because I am very busy at the moment. [Interruption.] That was an own goal.
We weigh and measure children at school, but to what end? Is it just another form-filling exercise, or is there a strategy to utilise the information and make sure that our young people and their families get the support that they need to live healthy lifestyles and lose weight? We cannot really remove exercise from the equation. Many teachers in my primary and secondary schools give up huge amounts of their personal free time to lead sports activities in the afternoon or evening. We need to encourage more teachers to do that, and if need be, we should make it worth their while financially.
Mr. Deputy Speaker, you have indulged me on occasions this evening and I thank you very much for your patience.
I am pleased to make a contribution to this important debate. I accept that, to an extent, the Bill focuses on the health sector and health care. However, I am a former social worker, a former teacher of social workers, and a one-time member of the Central Council for Education and Training in Social Work in Wales. I echo the words of the hon. Member for Blackpool, North and Fleetwood (Mrs. Humble): it is important that social care is not lost in the emphasis on health. The voice of the user must not be lost, either. That is one of the fundamental principles of social work and social care, and certainly something to which I attached great importance when I was teaching.
Much of the Bill applies to England, but there are some points that are particularly relevant to Wales. I want to emphasise that there might be some cross-border issues and I seek reassurance from the Minister that they have been taken fully into consideration. The Welsh Affairs Committee is mindful of the implications of cross-border issues for health care in Wales and will conduct an inquiry early in the new year.
There are particular arrangements in Wales. I would like reassurance that, for example, any implications of changes to the inspectoral arrangements in England have been taken into consideration. In Wales, we have our own body for regulating social workers: Cyngor Gofal Cymru, or the Care Council for Wales. It is separate from the General Social Care Council and operates on its own. Both bodies were set up under the Care Standards Act 2000. The Care Council is, like the General Teaching Council, a devolved body. However, the Care Council operates in the same area as the corresponding body in England and I am not wholly convinced that the operation of one will not have some influence on the operation of the other.
The care quality commission in England will combine health and social care and inspection. As I have said, I am concerned about whether there will be implications for the inspectoral arrangements in Wales, particularly on a cross-border basis and when staff move from one employer to another across the border.
The Care Council for Wales has a productive interface with health in Wales. There are regular meetings and training matters are discussed. However, it is important to realise that the work of the Care Council for Wales is not just focused on health. Its work also involves education, housing and community development matters. It works to a social model, not a health model. The care quality commission in England will combine health and social care inspection. Will the Minister let me know, either later or by means of a letter, what, if any, implications the Bill has for the inspectoral arrangements in Wales and the Care Council for Wales? Have there been discussions with the National Assembly Government and, if so, what were the conclusions?
I have a particular example. Should the Care Council wish to change, vary or develop its work, I take it that that could be achieved through regulation, under clause 114. I note that clause 115 states that the standard of proof that is to be applied may not be varied in Wales, as compared to England. Will the Minister confirm that the power through regulation will be sufficient and that there will be no need to transfer legislative competence over the Care Council for Wales to the National Assembly? Will there be a need for legislative competence orders? They are already coming through and can take some time. Has he had any discussions with the National Assembly for Wales on the matter? I might be worrying unnecessarily, but I would value an assurance from the Minister.
Clause 116 is on the training of mental health professionals. The regulation-making power for that lies with the Care Council for Wales. It is a Welsh matter, but again I hope that the Minister or his officials have had the opportunity to discuss it with the National Assembly. I am going into some detail, but I not seeking a place on the Committee. The Bill is largely concerned with matters in England.
My second group of concerns is about the Welsh language and the implications under the Welsh Language Act 1993. The provision of services by a public body is subject to the Welsh Language Board and operates under a Welsh language scheme that has been approved by the Welsh Language Board. I am thinking in particular of developing needs in relation to mental health. When people are assessed for compulsory admission, a language choice is available. To some extent, that will be a matter of regulation for the Care Council for Wales. However, the Mental Health Act Commission is being merged under the Bill. I want to be reassured that Welsh language issues have been taken into consideration.
I think great changes are going to be carried out in relation to mental health legislation in Wales. I mentioned compulsory admission. There is going to be a legislative competence order, which we hope will transfer to the National Assembly the right to legislate in this area. That is being proposed by a Conservative Member of the Assembly. The point is that the care quality commission will take on the duties of the Mental Health Act Commission in Wales and I want to be reassured that it will have a Welsh language scheme from day one. There was a discussion some time ago when the Children’s Commissioner for England was set up and had some duties as far as children in Wales were concerned. I had a long session with the relevant Minister to try to persuade her to set up a Welsh language scheme from day one. After 13 questions, she agreed to write to me, and eventually we got a Welsh language scheme. However, that scheme needs to be there from day one. After all, patients will have concerns from day one, particularly on the difficult matter of mental health.
There is considerable expertise in Wales on language matters, particularly in relation to social care and mental health. Looking at schedule 9, it seems that the principles of the Welsh Language Act should underpin provisions such as paragraph 2(e), which refers to standards of conduct, and paragraph (9), which imposes conditions for regulation.
I look to the Minister for reassurance that those particularly Welsh issues have been taken into account. Generally, I welcome the Bill, as other Members have.
I apologise to the House for the fact that I was not present at the beginning of the debate, but I wrote to the Speaker last week to explain why I would be late. I meant no discourtesy to the House. I have a particular interest in the Bill and I wish to make a brief contribution on Second Reading.
When merging the Mental Health Act Commission, the Commission for Social Care Inspection and the Healthcare Commission, I hope the Government will take on board the fact that there is such an overlap of service out there, and rightly so. The service that we should seek to provide, particularly for patients, should be seamless, but despite the Government’s best efforts to merge health and social services, we all still come across a great deal of casework in which it is difficult to take matters forward because of the glass walls that seem to exist between areas of responsibility.
The care quality commission that the Bill creates will be responsible for inspection and standards and will, we hope, facilitate crossover and ensure the seamless delivery of services. If the system is too compartmentalised, people’s conditions and the difficulties that they are encountering will fall down the middle. I am sure the Minister will take that on board. We need to address the matter, not least because, in the context of inspection, there are some groups for which we will have to provide to make sure that the services that are delivered to them and the way in which those services are delivered do not disadvantage them. I shall give two quick examples.
Across health and social services, we talk about adolescents, but whether we are talking about physical health, mental health or social services, all too often adolescents find themselves in inappropriate situations because sometimes it is difficult to judge whether children’s services or adult services are best for them, for obvious reasons. They are young people going through the transition from childhood to adulthood, and tailoring the services and the quality of the service or care that they are given can be a difficult call for professionals. I hope the Minister will accept that whatever system is put in place when the care quality commission comes into being, it will need to address the particular circumstances of adolescents and ensure that the service meets their needs and that the inspection reflects the issues.
Another aspect of the care quality commission that I want to raise with the Minister is the fact that the Government want to take away from the people responsible for inspections the right to look into second stage complaints from individual patients or, occasionally, patients’ relatives. Although the Bill does not focus primarily on that, will it give substantial reassurance about the system that is likely to replace that? I know that the Government are going out to consultation, but many of us feel unhappy that something is being taken away before we have a clear idea of what will replace it. I hope the Minister will address that.
Another issue that I shall touch on is the extension of direct payments. I declare an interest, as I am responsible for assisting a dependent adult relative who is the recipient of direct payments. I take co-responsibility with him and help him to complete his forms. I have been a great advocate of direct payments so I welcome the extension proposed in the Bill, but I flag up a concern. Apart from my constituency casework, wearing other hats I get involved in other casework around the country. Some authorities administer direct payments well, and others do not. Some seem to think that that is a cheap option.
Some authorities could serve as models of best practice from which others could learn. Will the Minister consider looking at those that perform particular functions well in order to encourage the others to go and learn? For example, I mentioned that I helped with paperwork. In the authority that I deal with—I should tell the Minister that it is not an authority in Devon—the process has been made so simple that it is a joy to undertake. In some authorities, however, where people have been asked to make arrangements to buy in their own services, existing services have been removed and people have been left floundering, trying to find out where they can buy in.
The extension that the Government propose deals particularly with extending direct payments to those who lack capacity. They will be least able to shop around without a little guidance, not least to ensure that they are buying from a bona fide provider. We all know the difficulties for those who lack capacity, especially if they are not assisted by an immediate carer. Not all of them have an immediate carer to guide and assist them in buying in their package. Direct payments are a great idea, but one or two details need tidying up in order to improve the service, especially if it is to be extended to that group.
I was not in the Chamber earlier, so I shall not dwell on my next point. I flag up to the Minister a concern about clause 145, which deals with electronic records. I am sure that my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) on the Front Bench and others raised the matter. In the light of recent events, there is clearly a need to get the provisions spot-on. I hope the Minister will go back to the drawing board to make doubly sure that this part of the Bill will be a new dawn in the collation and management of electronic records.
The House has been generous in allowing me to speak, even though I was not present earlier. I have one further point. Across health and social services, there is one group of people who worry us all enormously. In his speech my hon. Friend the Member for Broxbourne (Mr. Walker) touched on the care of the elderly. There are issues such as end-of-life care, of which we have all had experience in our personal lives or in the casework that we have dealt with.
The Government should focus on the inspection and delivery of end-of-life care. Very elderly people, often unsupported by immediate family or friends, struggle when they go into hospital or into residential or nursing care, at a time of their life when the service should be a Rolls-Royce service. If we do not give priority to people at the very end of their life, that is an indictment of us as a society and as a country. I hope the Minister will bear that in mind when he brings the Bill to the Committee.
It is a privilege to follow my hon. Friend the Member for Tiverton and Honiton (Angela Browning), with her deep commitment and expertise in health and social care. I pay tribute to all that she has done to help all of us in the House, without fear or favour, to chart our way through difficult and sensitive matters.
We have had wide-ranging debate this evening, as befits such a wide-ranging Bill. My hon. Friend the Member for South Cambridgeshire (Mr. Lansley) called it a portmanteau Bill. My right hon. Friend the Member for Witney (Mr. Cameron) has made it clear that when the Government are doing the right thing for the country, we will work with them. Indeed, we will encourage them to go further, where that is the right thing to do.
In some crucial areas the Bill does not go far enough. Although we support it in principle, and do not intend to divide the House on it tonight, we look forward to developing the Bill to benefit patients and front-line health care professionals, not least by importing aspects of our own White Paper, which we have already published—although I shall, of course, try to stay in order. I am aware that Ministers have been provided with copies, which I hope they have read from cover to cover. We have published the NHS autonomy and accountability Bill, which, unusually, we will introduce during this Session. We want to include, at last, our proposals for a genuine patients forum that has teeth and independence—HealthWatch.
We looked in vain in the Bill for the vision and the overarching transformation, the prospect of which the Prime Minister, on taking office recently, highlighted. However, so far we have been disappointed, as was rightly noted by my hon. Friend the Member for Preseli Pembrokeshire (Mr. Crabb) in an analytical and powerful speech; I hope that we shall have his cogent participation in Committee. My hon. Friend was right to observe that the Bill is no testament to the Prime Minister’s aspiration for a vision—if, that is, he is still looking for one.
It is also worth noting that of 161 clauses, 38 depend on future regulations, the majority of which will be subject to the negative procedure. It is a great shame that the Government are too nervous, or lack the confidence, to bring forward a substantive debate on the Floor of the House on many of the measures. We shall seek to debate them in Committee, and I hope that the Minister will make available to the Committee in good time the draft regulations and examples, so that we can debate the best interests of patients and the public, rather than the leviathan power of the Secretary of State.
It would have been helpful of the Minister to have started by demonstrating his good intentions and informing the official Opposition that he was publishing today—the day that we are debating the Bill—the draft section 60 order. He did not mention that to me at the briefing meeting that we had a few days ago. I hope that he will be able to make up for that lack of foresight.
We might also note that 10 of the major provisions in the Bill do not carry an impact assessment, including the creation of the office of the health professions adjudicator, the health in pregnancy grant and the devolution of the pharmacy global sum to primary care trusts. One has to wonder whether the Government think so little of their own policies that the impact is not worth assessing. More worrying is the question of whether the work has been done, and is available for scrutiny by the House.
The hon. Member for Caernarfon (Hywel Williams) discussed cross-border concerns. As an MP with an English constituency that borders Wales, I am all too well aware of the complexities and difficulties, and the fact that citizens on both sides of the border often seriously feel that there is a lack of fairness in respect of the health or social care provision that they receive.
The hon. Gentleman has been following the Bill a little more closely than I. Can he tell us whether there is a legal aid impact assessment, which I believe all Bills should have? There may be a legal aid aspect; people may go to the new body for assistance with judicial review, for example.
I do not know what the current status of the hon. Member for Wolverhampton, South-West (Rob Marris) is in the law.
I hope to develop this point a little later, but it is interesting that the proposals are not clear about whether somebody subject to the adjudication process has rights of representation. They might need to avail themselves of legal aid, irrespective of the hon. Gentleman’s point. I have not seen whether there is a legal aid impact assessment, but the fact that I did not see one on my first reading did not surprise me.
I should like to highlight the point made by my hon. Friend the Member for Tiverton and Honiton on the direct payment extensions. There is unquestionably a lot to be done to iron them out so that they are smooth-running. However, there is no question but that as a matter of principle they are the right way to go when they fit the circumstances of both the cared-for person and the person who assists. Most importantly—and this point cross-refers to other elements of the Bill—my hon. Friend was absolutely right to highlight the fact that the Government have not put forward proposals for benchmarking and the transfer of best practice. That proposal was extremely constructive. I hope that we may have the benefit of hearing more about it if my hon. Friend is lucky enough to be considered to serve on the Committee.
In his authoritative and all-encompassing speech, my hon. Friend the Member for South Cambridgeshire made clear our position on the care quality commission. [Interruption.] I did have to say that—because my hon. Friend’s speech was considerably more impressive than the Secretary of State’s. The Government are moving in the right direction, but they have not gone far enough, as I have said. In the simplest analysis, the CQC will not be independent of Ministers, despite the Secretary of State’s claim. As the hon. Member for Wyre Forest (Dr. Taylor) observed, the legislation fails to set out the commission’s core duties and responsibilities beyond the most anodyne of statements coupled with a crude fining system. At this point, we should note the genuine demand for the seamlessness mentioned by my hon. Friend the Member for Tiverton and Honiton.
I hope that the Minister will take the opportunity to answer the question put by my hon. Friend the Member for South Cambridgeshire. It was about the Appointments Commission, which is currently responsible for the appointment of the chairs of the Healthcare Commission and the Commission for Social Care Inspection. In his answer, the Secretary of State said that that would not be the case for the CQC because the job was so important that it could not be left to the Appointments Commission. That answer was most surprising, and I dare say he may reconsider it.
Until our proposals for an NHS autonomous of ministerial meddling, with separate and independent quality and independent regulators to support it, are delivered, the Bill will do little more than bring about an amalgam of existing bodies, with their existing constraints. Furthermore, without a strong national patient voice, that regulator will lack the necessary checks and balances to operate most effectively . We hope that the Bill provides the opportunity for us to seek to strengthen LINks to provide that.
The hon. Member for Blackpool, North and Fleetwood (Mrs. Humble) rightly advocated listening to the voice of the user. The hon. Member for North-West Leicestershire (David Taylor) advocated the use of citizens councils; that idea might go a little further than most of us would wish. However, I hope that his point is at least explored in Committee so that we can discuss its merits and demerits.
Another question was raised that remains unanswered; perhaps the Minister will take the opportunity to answer it when he winds up. In the development of the new institutions, the complaints system is effectively being taken back fully in-house. There is a big question mark about the absence of true independence; a question was raised about whether the health service ombudsman has the capacity to deal with the anticipated higher incidence of complaints that will find their way to his desk. That point, too, was emphasised by the hon. Member for Wyre Forest. I hope that the Minister will clarify the issue.
Many organisations have expressed concern that the experience built up by the Mental Health Act Commission, the Commission for Social Care Inspection and the Healthcare Commission will be lost. We shall seek assurances from the Government that the establishment of the CQC will not mark yet another year zero, particularly given the continual upheaval that the Government have brought to social care regulation. My hon. Friend the Member for Broxbourne (Mr. Walker) made a serious and passionate speech in which he made it clear that we also need to make sure that the Government give assurances that the social care and mental health responsibilities of the CQC will not be squeezed out by its Healthcare Commission-type functions. For example, have the Government made allowances for the impact of community treatment orders on the work of the MHAC? What work will the CQC do in prison health care? That point has not been raised. We should consider the point, raised by my hon. Friend the Member for Worthing, West (Peter Bottomley) in his excellent and comprehensive speech, about the appropriate use and deployment of magistrates under the Bill.
My hon. Friends have deplored the Government’s failure to combat health care-associated infections effectively. That the Government are embarrassed by that is clear from the fact that the relevant provisions are buried deep in the Bill. However, we guarantee—as will others from across the House, I am sure—to make sure that Ministers are engaged in a frank and open debate as we go through the Bill’s parliamentary stages.
As for professional regulation, we want proportional regulation that protects patients and the public, as well as innocent doctors. My hon. Friend the Member for South Cambridgeshire flagged up our debates on the role of the office of the health professions adjudicator. If Ministers believe in self-regulation, as we do, why is the OHPA required? We must leave that question hanging for them to answer, today or in Committee. It was interesting to hear from the right hon. Member for Rother Valley (Mr. Barron) about his experience of serving on the General Medical Council, which raised the question of why it is necessary to have another body in addition to developing the role of the GMC. His speech was restricted to that subject, but I hope that as Chairman of the Health Committee he will devote some time to, and take equally seriously, the social care aspects of the Bill.
I might have to lie on the couch to think about that. I do not see it as being within the scope of the Bill—far from it. It is the subject of numerous submissions and considerable argument, and it would be much better for us to discuss it in a rather more serious and considered way than in this very short exchange.
My hon. Friend the Member for South Cambridgeshire has helpfully found an assurance for the hon. Member for Wolverhampton, South-West on his earlier intervention about the legal aid test. I draw his attention to annexe C1 of the impact assessments document, which says:
“As stated in the evidence base, it is not expected that the number of orders made to a justice of the peace, (currently approximately 10 orders per year) or the numbers of prosecutions (currently none brought) will significantly increase. Therefore there is likely to be little impact on the work of the courts. Consistent with this, there is likely to be little impact on legal aid.”
It does not address the question of the impact on the health service ombudsman, who would be the point of appeal of last resort.
There is another matter that we need to be clear about as regards professional regulation. We know for sure that strong submissions will be made to the Committee about the proposals on the standard of proof. I reconfirm that we support the change from a criminal to a civil burden of proof in principle, but the Government have not yet provided clarity on the flexibly applied nature of the imposition of the new standard. We will not only seek to draw out the likely impact of the changes but seek assurances on the application of the sliding scale. I submit that evidential proof should be to the civil standard but, given that the ultimate sanction is to deny somebody their living, the procedural rules should be as for a criminal case, where someone knows the evidence against them well in advance and has the opportunity to test it extensively. I also hope that the Government will entrench in the Bill a more positive approach to professional regulation, bringing greater opportunities for benchmarking and professional development.
Hon. Members raised several points about public health and health in pregnancy. My hon. Friend the Member for Guildford (Anne Milton) will take those matters through Committee, so I shall leave them for her to develop extensively. Interestingly, the miscellaneous provisions are quite substantive. In its breadth, the Bill gives us an opportunity to debate several key issues regarding the provision of health and social care. Sadly, the solutions proposed by the Government do not appear to be sufficient or sufficiently focused. That is true of this Bill as of so many others. That gives us the chance to try to improve it immeasurably, and I hope that we can do so for the sake of the future health care of our constituents, patients and the public. It is our social responsibility to give them the social care that they deserve.
This has been a wide-ranging, well informed and constructive debate. I am pleased that the main provisions of the Bill appear to enjoy broad support across the House, and I look forward to debating them with hon. Members in more detail in Committee. I will try to respond to as many of the points raised during the debate as possible, but if I omit some I will endeavour to write to hon. Members with the answers to their questions.
My right hon. Friend the Member for Rother Valley (Mr. Barron), who is Chairman of the Health Committee, made an interesting speech based not only on his chairmanship of the Committee but on his long-standing membership of the General Medical Council. I listened with great care to what he said and hope to use a lot of it when dealing with the detail in Committee. I am pleased that he welcomed the broad thrust of the Bill. He also welcomed the move to an integrated regulator. I entirely agree that that transition needs to be handled with care, as other hon. Members said. I also noted his welcome for the reform of professional regulation based on his GMC experience. I agreed with everything that he said about that. He rightly pointed to the important role of responsible officers. They were not explicitly mentioned in Dame Janet Smith’s inquiry, but, in response to a point made by the Opposition spokesman, I can say she dealt with what they will deliver in her recommendations. As my right hon. Friend alluded to, having responsible officers should mean that we can avoid the situation where many cases that could be managed and resolved locally have to go to the top. I hope that we all welcome that.
My hon. Friend the Member for Blackpool, North and Fleetwood (Mrs. Humble), who is the chair of the all-party group on this matter, spoke with a great deal of expertise about social care. She welcomed much that was in the Bill, such as health in maternity grants and the direct payments, although she wanted those to be handled with care, as did the hon. Member for Tiverton and Honiton (Angela Browning). I absolutely agree with her about that. She raised a concern that several other hon. Members raised, and the Commission for Social Care Inspection has raised it with me at several meetings. I hope that I have reassured the commission that the integration of the three regulators will not mean that it or the mental health body are overwhelmed by the health body. Both now and in Committee I hope to give my hon. Friend the reassurances she seeks. She is absolutely right about the need to handle carefully the integration of the different cultures involved. She was right when she said that the social care sector brings something new to the party—something from which the health sector can learn. I will take on board her remarks when the Bill passes into Committee.
My hon. Friend used the term “light touch”, and it was used by one or two other hon. Members as well. I prefer to use the term “risk-based and proportionate”. Having read the Bill, she may have noted clause 2. I hope that it will reassure her on the issue of vulnerable people because it makes it clear that the new regulator must pay heed to the safeguarding of vulnerable adults and children in the fulfilment of its duties. She also asked about self-funders. I have discussed that matter with the Under-Secretary of State for Health, my hon. Friend the Member for Bury, South (Mr. Lewis), and we recognise the issue. We are considering how we can use the regulatory powers in the Bill to address the matter as it passes through the House.
The hon. Member for Worthing, West (Peter Bottomley) made a very positive contribution on public health, and on how the health in pregnancy grant needed to be seen in the context of public health more generally, including pre-conception health. I entirely agree with that. He pretty much supported the changes that will be made to regulation. He raised a point that was made by Liberty. I am afraid that I have not had sight of that, but I will find out about it, and write to the hon. Gentleman and Opposition Front Benchers about the role of magistrates and detention. I assure him that the consultation will be genuine.
My hon. Friend the Member for North-West Leicestershire (David Taylor) spoke largely about the role of citizens councils. I hope that the new regulatory regime in the Bill will provide him with the reassurance he seeks, but I shall reflect on the suggestion that he made about the role of citizens councils, particularly under the auspices of the Council for Healthcare Regulatory Excellence. I am sure that he realises that the lay membership of the CHRE is being reduced because the overall membership is being reduced. The regulatory representatives are leaving because we do not want it to be a body that is made up of such representatives; we want it to fulfil a slightly different function. It will be smaller, and I shall certainly look at his idea. The CHRE has a duty under the proposals to consult the public and organisations representing patients’ interests, so there may be scope for considering it.
The hon. Member for Preseli Pembrokeshire (Mr. Crabb) was critical, slightly unfairly, of the health in pregnancy grant. Other grants are already available that address some of the issues he referred to in relation to early pregnancy, and they are means-tested. There is evidence to suggest that mothers, particularly the less well-off, spend money that they are given in the interests of their children, both born and unborn. There is evidence from countries that grant similar help—Finland, Belgium and France—that it addresses the serious problem of low-weight babies, which, I am afraid to say, we still have in this country. We do not have a very good record on that. His point about termination was another argument for making the grant at 25 weeks, if I may put it like that.
My hon. Friend the Member for Dartford (Dr. Stoate) raised wider issues of obesity, most of which are outside the scope of the Bill, but it was still a good speech. I agreed with almost everything he said. As a former chairman of the all-party group on cycling, he would expect no less. I hope that some of the issues that he raised will be addressed more comprehensively when we come to publish our forthcoming obesity strategy.
On the issue of pharmacy and the global sum, which was also mentioned by the hon. Member for Romsey (Sandra Gidley), I hope that I can reassure my hon. Friend that PCTs will not simply be able to siphon off the funding for pharmaceutical services or to vary nationally negotiated fees and allowances for essential and advanced services. They will continue to be set nationally. I am intensively engaged with the pharmaceutical representatives, as is my right hon. Friend the Minister of State. When we come to publish the White Paper there will be huge possibilities for pharmacy and for pharmacists, particularly in primary care, to deliver the vision that is shared by both sides of the House.
The hon. Member for Wyre Forest (Dr. Taylor) welcomed the move to an independent regulator. He said that we were short on listing its duties but I refer him to clause 2, which lists those duties fairly comprehensively. A balance must be struck when setting up an independent body as to how much one can dictate its duties and how it is expected to fulfil them. We have struck a good balance with the duties that we expect the regulator to fulfil and how it should go about them. We do not want to put it in too much of a straitjacket, because that would compromise its independence. We are trying to strike the right balance.
The hon. Gentleman managed to spot an important element of the Bill that was not spotted by anyone else. That was the role that the commission will play in PCTs and commissioning, which is vital if the new independent body is to have the role that we think that it needs. The current body does not have that role. The hon. Gentleman was right to highlight the importance of that.
We dealt with LINks during the hon. Gentleman’s speech. LINks do not come within the scope of the Bill, as they are already on the statute book. We have told the Healthcare Commission that we expect the new regulatory body to work closely with LINks on inspections and on how it goes about its work. The body should consult LINks and work closely with them. The commission will have a duty to have a panel made up of patients’ representatives to advise it. I have not had sight of the TUPE issues, but I shall find out about them and write back to him.
The hon. Gentleman also talked about complaints, as did a number of other hon. Members. I think that I share their concerns. There should be recognition from all parties that the way in which a lot of health organisations on the ground handle complaints is not great. We want to try to reduce the number of complaints that are not handled well locally. The ombudsman—we should say ombudswoman in this instance—will deal with second stage complaints. We have discussed capacity with her and she is satisfied that she will not be overburdened, but we will have to deal with those issues carefully.
We did not want to burden or slow down the work of the important new regulatory body, whose main priority will be safety and quality for patients, by making it deal with complaints. That should force us all—and the health service in general—to do a better job of dealing with complaints. Of course, the new care quality commission will have a role in deciding whether organisations deal with complaints properly. Nothing will stop a patient from making a complaint as in the example of Cornwall. That led to an important and far-reaching inquiry.
The hon. Member for Broxbourne (Mr. Walker) rightly recognised the important role that the care quality commission will play in helping to continue to drive down health care-acquired infections. The hon. Member for Caernarfon (Hywel Williams) asked about a number of Welsh issues. I am assured by my officials that they have worked closely with Welsh colleagues and that we have agreement with Welsh Ministers on those issues on which we will need to agree. I am assured that we have been taking the Welsh language issues seriously, too. I shall write to the hon. Gentleman with clarification on the other detailed points about the Welsh perspective that he mentioned.
I do not begrudge the fact that the hon. Member for Tiverton and Honiton was late. She made an important contribution as always, based on her long personal experience, about the need for seamless service and a seamless system of inspection. It is right that we should focus on that when we discuss the issues in more detail in Committee. She also mentioned complaints, which I have dealt with. She supported direct payments, which I was pleased to hear, but she thought that best practice needed to be learned from. I agree entirely. The new regulator may want to consider how practice can be improved across the piece to bring the performance of those local authorities that are not as good up to the level of the rest.
The hon. Member for Romsey, who speaks from the Front Bench for the Liberal Democrats, broadly welcomed the Bill but did not believe that there should be a one-size-fits-all approach. I agree. The new commission needs to take a proportionate, risk-based approach that takes on the strengths of the three existing organisations. It needs to be sensitive to their strengths and differences. I hope that I can reassure her through my comments on Second Reading and in Committee that fears of health domination are not justified. When the Bill was published, we held intensive discussions with all three organisations and they broadly welcomed it.
I was disappointed when the hon. Lady described the health in pregnancy grant as a “bit of a gimmick.” It is not. Some people may think that £190 is not much, but it means a great deal to many women in my constituency. It will be an enormous help to them in those last few months of pregnancy when they have to make difficult choices about spending priorities. I am sure that the hon. Lady did not mean to suggest the contrary.
I will write to the hon. Lady about body mass index. I understand that we are considering the matter. One difficulty is that many people do not understand what body mass index means whereas they understand height and weight. We are also considering the follow-up for parents to give the provision more substance.
Someone mentioned the Human Rights Act 1998 and independent sector homes. We hope to be in a position to tackle that in the forthcoming Green Paper on the British Bill of Rights and duties, which would allow us to deal with the matter in the wider context of the public authority definition. Including that definition in the Bill causes a problem because it is so vast. However, we will strengthen the regulatory powers in the measure to ensure that the care quality commission can enforce the requirements in line with the relevant provisions of the Human Rights Act.
The hon. Member for South Cambridgeshire (Mr. Lansley) asked about the independence of the appointments system for members of the care quality commission. I assure him that the Bill proposes no change. The Secretary of State already has such a power but he devolves it to the Appointments Commission. We have made it clear that that will continue.
We have heard a little from the Conservatives today about their alternative Bill. We welcome some of their suggestions—indeed, we are already implementing them. We especially welcome their professed conversion at last to a taxation-funded NHS free at the point of need. However, their alternative is also deeply flawed. It professes to support devolution to the local level, yet Conservatives want to stop all local reorganisations of services, whatever their clinical merits. They call it a moratorium on reconfigurations; I call it a moratorium on saving lives. They talk about local and national accountability, but want to hand the big decisions to an unelected quango of bureaucrats.
Since 1997, we have put record investment into the NHS, making genuine improvements in care, slashing waiting times, saving lives and boosting quality of life. Reform has come with that investment, driving up standards, giving patients genuine choice and improving efficiency. There have been continued real-terms increases in investment in health. The Bill will build on those achievements, leading to fewer quangos, less bureaucracy, better safety and quality, more transparency and genuine accountability—a health service fit for the aspirations of the British people. I commend the measure to the House.
Question put and agreed to.
Bill accordingly read a Second time.
HEALTH AND SOCIAL CARE BILL (PROGRAMME)
Motion made, and Question put forthwith, pursuant to Standing Order No. 83A (Programme motions),
That the following provisions shall apply to the Health and Social Care Bill:
1. The Bill shall be committed to a Public Bill Committee.
Proceedings in Public Bill Committee
2. Proceedings in the Public Bill Committee shall (so far as not previously concluded) be brought to a conclusion on Thursday 24th January 2008.
3. The Public Bill Committee shall have leave to sit twice on the first day on which it meets.
Consideration and Third Reading
4. Proceedings on consideration shall (so far as not previously concluded) be brought to a conclusion one hour before the moment of interruption on the day on which those proceedings are commenced.
5. Proceedings on Third Reading shall (so far as not previously concluded) be brought to a conclusion at the moment of interruption on that day.
6. Standing Order No. 83B (Programming committees) shall not apply to proceedings on consideration and Third Reading.
7. Any other proceedings on the Bill (including any proceedings on consideration of Lords Amendments or on any further messages from the Lords) may be programmed. —[Liz Blackman.]
Question agreed to.