Considered in Grand Committee
My Lords, the regulations before the Committee today relate to the registration of providers of NHS primary medical services with the Care Quality Commission. The effect of the regulations is straightforward. It defers the registration of most providers of NHS primary medical services by 12 months, until April 2013. The registration of a small number of out-of-hours providers of such services will still go ahead in April next year, and the commission has started the process of registering these providers.
As the independent regulator, the Care Quality Commission has a key role in assuring the public and people who use services that health and social care providers of “regulated activities” meet certain requirements. In order to be registered, providers must meet a series of essential safety and quality requirements on an ongoing basis. Where a registered provider fails to meet these requirements, the CQC has a range of enforcement powers that it can use to bring a provider back into compliance. In the case of the most serious failings, the CQC is able to cancel a provider's registration, which would result in the provider's closure.
The Committee will be familiar with some of the criticisms that have been levelled recently at the CQC, in particular that the number of inspections of providers that it carries out has fallen to unacceptably low levels and that it failed to respond appropriately to serious service failings, most notably in the case of the appalling abuse of residents at Winterbourne View, a hospital for people with learning disabilities.
The Government attach the highest importance to the role of the regulator in carrying out its statutory functions in an efficient and effective manner. The regulations before us are part of the process of how we and the CQC respond to these issues. Deferring the registration of around 9,000 providers of NHS primary medical services will give CQC additional time both to improve the registration process for this tranche of registrants and to increase the compliance activity of providers that are already registered with it.
Implementing the new registration system has required the Care Quality Commission to register around 21,000 providers already, bringing in, first, NHS providers; then independent sector healthcare providers and adult social care providers; and then independent ambulance and primary dental care providers. This has been a major programme of work for the CQC, which it has carried out well. However, given the scale of the task, it is perhaps not surprising that the number of compliance inspections carried out by the regulator fell. The current timetable set in regulations brings providers of NHS primary medical services into the registration system in April 2012. This would bring in around 9,000 additional providers and includes GP practices, out-of-hours primary medical care providers and some NHS walk-in centres.
Although we remain committed to the registration of providers with the CQC and are confident that this will provide effective levers to tackle providers who deliver sub-standard care to patients, we have reconsidered the timing of registering the majority of these providers in the light of the challenges that the CQC has faced. Following a consultation that came to an end in July, and engagement with key stakeholder representatives, we have decided that providers of NHS primary medical services who provide out-of-hours care to patients who are not registered at their practice will be required to register with the CQC as planned from April 2012.
Out-of-hours services tend to treat unfamiliar patients in unfamiliar surroundings and see a higher proportion of vulnerable patients with urgent care needs that are often more complex than those generally found in daytime general practice. As such, there is a more pressing need to register these services than other NHS primary medical services, which is why we are forging ahead with the registration of this group of providers. All other providers of NHS primary medical services will now be required to register in April 2013. The regulations before us amend the regulated activities regulations in order to achieve this delay.
In parallel with our consultation on the proposed changes, the CQC has reviewed its registration process, looked at streamlining its registration systems, and is increasing its scrutiny of providers that it already registers. Consultation responses made clear that a streamlined process would be welcomed. I am pleased to assure the Committee that the commission is taking steps in this direction. On the registration process for primary medical services, I am informed that the CQC is overhauling its online application process so that providers will be able to start completing the application sooner than in previous application rounds. The website will contain full information on the registration process and will provide updates on the progress of an application and how long it is anticipated that it will take for key decisions to be made. The CQC will also put in place a central team to handle applications, avoiding the risk of the registration of NHS primary medical care providers impacting on the CQC’s ability to monitor the compliance of other registered providers. Noble Lords may recall that there were delays in registering dental practices earlier this year due to the volume of Criminal Records Bureau checks required. The CQC is considering a different approach, which I am assured will go a long way to resolving these problems.
The CQC will engage with providers of medical services over the coming months to ensure that they have a clear understanding of what registration will entail and how compliance with the registration requirements will be assessed. The CQC’s compliance inspections have been increasing steadily since the spring. and I am confident that the delays proposed and the arrangements the commission is putting in to handle registration in April 2013 will allow this to continue and be sustained.
Looking beyond initial registration, the CQC is also proposing changes to strengthen and simplify its regulatory model. Importantly, the commission is planning to increase the number of inspections that it carries out. These proposals would see all registered providers of hospitals, social care providers and independent healthcare providers being inspected at least once a year, with primary dental care providers inspected at least once every two years.
I hope that the Committee will be reassured by the progress that the CQC is already making to improve its registration processes and to increase its focus on compliance and inspection. The delay to the registration of providers of NHS primary medical services that we are considering today will allow the commission the space and time that it needs to move further in this direction more quickly. I commend the regulations to the Committee.
I thank the Minister for his remarks about the regulations. I must admit that when I read the words:
“These Regulations may be cited as the … Regulated Activities … Regulations”,
I felt as if I was participating in a Marx brothers’ movie, as you wonder which part relates to which. However, behind the regulations lies a very important human story. I want to focus my comments and questions on some of those issues. The Minister referred to the fact that in respect of NHS primary care services there is clearly a risk that the problems which the Care Quality Commission faces now could still apply in 2013. Apart from simply delaying the requirement to register again, has the Minister any other contingency plans to deal with the capacity problems in the CQC?
A human-issue story concerning out-of-hours services relates to the report that the CQC wrote arising out of the Daniel Ubani case, where the real risk posed to patient care from out-of-hours services was apparent. I would like the Minister to spell out how the small number of—
Sitting suspended for a Division in the House.
I have received a warning that I must not repeat myself, so I shall try to start from where I left off, which was highlighting the CQC report on out-of-hours services arising from the Daniel Ubani case, which highlighted that we have a nationwide problem. Delaying the requirement to register for a further year means that a lot of the issues that need to be addressed by proper monitoring of compliance will not be.
My other questions relate to which organisations are covered by the regulation. The estimate was about 230 organisations. Does that include the co-operatives such as SELDOC, established in south-east London? Is it simply those organisations separate from GPs? There is an issue about high-risk out-of-hours services stemming from provision within GP services by the use of locums employed directly. I would appreciate clarity about the risk assessments. What concerns me most is that within a 12-month period, the Care Quality Commission will be required to get in to 9,000 organisations, but the Government have given it 12 months to deal with about 230. Having been on the commission’s website and seen the processes and procedures, and the advice being given to primary health services, I think we have a difficult job ahead of us.
I leave my remarks to those few specific points. On the extension of out-of-hours—I must not say out-of-office services, that is my trade union background coming out—the flexibility of the provision of services by primary health services is most important. People are reverting to organisations that do not have their medical records or knowledge of their conditions because they have to work and cannot get to a surgery within its opening times. I know from personal experience that even booking a medical appointment can be extremely difficult. You have to do it within a particular time frame. With those concerns, I leave my remarks.
I should like the Minister to clarify one point. Out-of-hours services providers need to register a year early if they are not in the practice of treating patients from outside their area. Can the Minister clarify the situation regarding itinerant or travelling workers? Where I come from, huge swathes of people come in to pick strawberries, daffodils or whatever. They certainly do not register. I am not clear whether the out-of-hours providers would treat them as temporary residents. What is the case in those circumstances? Would GPs who currently provide services in Cornwall in a co-operative be required to register a year early?
My Lords, I, too, have a couple of questions. I very strongly support my noble friend's question about itinerant or temporary workers. In addition to the people about whom the noble Baroness, Lady Jolly, spoke, there is also the Traveller community, which does not stay permanently in a single place, as we know from the Dale Farm episode. I am very concerned—I am sure that others in the Committee are, as well—about the position of mobile workers whose life involves moving from place to place, and about where they will be picked up by the providers.
My second question concerns the position of out-of-hours services. The General Medical Council has raised many concerns about out-of-hours providers who are not familiar with the English language, let alone some of the other languages that we have in this country. Will there be additional requirements for out-of-hours service providers above the basic medical requirements that they will have to meet?
I should know the answer to my third question, but I confess that I do not. However, I am sure that the Minister does. When providers are registered, are the lists of those who are registered made available to local HealthWatch committees, local authorities and Parliament? That is very important. Transparency is almost invariably the best form of inspection.
Finally, with regard to the CQC, we all know—as the noble Lord and the noble Baroness, Lady Thornton, said—that it has been under heavy pressure. My question is: will the practice of non-notified inspections, as well as notified inspections, continue? I note that the Secretary of State referred to this just a couple of weeks ago in respect of the investigation of complaints about the treatment of elderly people when he called on the CQC to do an immediate inspection.
I have one final point. I do not expect the noble Earl to reply if he does not want to. The most effective form of inspection is by protecting whistleblowers. All of us are aware that whistleblowers are a very effective form of informal inspection. It was whistleblowers who came up with the terrible Winterbourne story. Are there any means of protecting whistleblowers, especially among NHS staff, from being forced into retirement or sacked? Among all possible forms of inspection, NHS staff are most likely to be able to alert the system too bad or poor standards. Have we given consideration to the possibility of protecting whistleblowers among NHS staff? I am sure that our colleague from the trade unions would be sympathetic to that idea.
My Lords, noble Lords asked number of questions. The noble Lord, Lord Collins, focused in particular on the capacity of the CQC to fulfil the remit that we gave it. He questioned its ability to register 9,000 providers in 12 months. He will not be surprised to hear that we asked the same question of the CQC. We were assured that it is well placed to do that. It has registered 21,000 providers since April 2010. As I mentioned earlier, it is streamlining its processes to achieve the registration of primary care providers. However, the registration of primary dental care providers and independent ambulance providers in April 2011 highlighted the need for the CQC to make improvements to the registration process. In the light of that, we believed that it was preferable to delay registration by a year, during which time the CQC would be able to modernise and streamline its processes and tools so that the process runs more smoothly and is less burdensome both for providers and the CQC itself.
One of the main purposes of deferring the registration of providers of primary medical services was to provide the CQC with the space to improve its systems. We considered walk-in centres in this context. We perceived that there was a serious risk of capturing a significant number of providers under the definition of an NHS walk-in centre. We have concluded that rather than risk overburdening the CQC with a large number of applications in 2012, we will postpone the registration of these providers for 12 months. We believe that this will provide the CQC with the necessary breathing space. The CQC is already contacting those providers who it believes will need to register in April 2012 in order to start the registration process. The CQC will also work with other providers of NHS primary medical services and their representative organisations to identify and develop proposals to streamline the application process that will apply to those who are required to register in April 2013.
The noble Lord also asked me about the CQC’s resources. Each year the CQC agrees its business plan and financial allocation with the Department of Health. The CQC’s financial position is then kept under constant review during the financial year. The Department of Health has now agreed a business case submitted by the Care Quality Commission requesting approval to recruit additional compliance inspectors and compliance managers in order to undertake more frequent inspections. This approval has been given as part of the ongoing 2012-13 finance and business planning round and the CQC’s indicative revenue budget for next year includes sufficient funding to allow the CQC to recruit the additional 229 full-time equivalent compliance inspectors and the additional 19 compliance managers that it requested.
As I indicated earlier, we considered whether there were different risks in the provision of out-of-hours care to justify registering providers of those services ahead of providers of other NHS primary medical services. The case of Dr Ubani has been mentioned, which is very pertinent in this regard. Many respondents expressed the view that there were strong reasons for us to register these providers next year. While there is little concrete evidence to demonstrate that there are greater risks in the provision of these services, we believe that there are material differences in the type of service they provide which justify their earlier registration. As I indicated earlier, some of the differences revolve around the fact that often out-of-hours services practitioners treat unfamiliar patients and see a higher proportion of vulnerable patients with urgent care needs, sometimes with more complex needs. That persuaded us that there was a more urgent case for registering those providers before the others.
The noble Lord made the very good point that in primary care nowadays an increasing range of services are provided. That is why the previous Government approached the question of regulation in the way that they did. Instead of defining scope in terms of organisational settings; for example, hospital and care homes, there is a list of regulated activities for which registration is required. This means that regulation is based on risk of harm to those receiving the care or treatment rather than inflexible organisational structures.
This system of registration is flexible so that it can adapt to new and innovative service models. Basing the scope of registration on activities rather than settings means that regulation provides the same level of assurance wherever people choose to access care or treatment. In other words, legislation describes what providers must do, not how they must do it.
My noble friend Lady Jolly asked me a number of questions, in particular, about itinerant, travelling workers and how they are treated. The fact that a primary care provider accepts patients temporarily will not itself trigger registration from 2012. Those patients are likely to be temporary residents if they seek to access GP services in a particular area. I will write to my noble friend to clarify that, because I am sure that there are detailed issues within that question and I do not want to mislead her.
My noble friend Lady Williams also picked up that point and asked me about language requirements on out-of-hours providers. The language requirements are currently picked up under the system by which PCTs commission out-of-hours care. It is not open to the GMC, when registering a doctor who is registered abroad, to language-test that doctor, but employers clearly have a duty to ensure that any doctor employed in an out-of-hours service is capable of communicating with patients. The employer should ensure that patient needs in an area are being appropriately met by those who are charged with looking after them out of hours.
My noble friend also asked whether the list of registered providers will be available to local HealthWatch and to Parliament. I am advised that the list is available on the CQC website. Some bodies require notification, and HealthWatch England will be part of the CQC, if Parliament approves our plans, so there will be an automatic route of communication between the CQC itself and HealthWatch England.
My noble friend also asked me about whistleblowers. NHS workers are currently protected by whistleblowing legislation. The CQC is a named body under the Public Interest Disclosure Act, which protects whistleblowers. We are very keen that there should be no deterrent to whistleblowers. It was obviously concerning to see a case reported last week where a whistleblower was put under pressure by colleagues. We are looking at the implications of that case very closely. I cannot say more to my noble friend at the moment on that.
Committee adjourned at 4.49 pm.