Health Bill [HL]

My Lords, I am slightly nervous about standing up, after what the noble Baroness said about the clarity of my thoughts. I will have a go at being clear. I declare an interest as chairman of the Care Quality Commission, which in 55 days—I also thank the noble Baroness for having calculated that figure—on 1 April becomes the regulator of quality of care across healthcare and social care in both the public and private dimensions. I am a great fan of the NHS Constitution; it is vital that users, carers and their families have a right to quality. I hope that we can make the constitution not just an ephemeral thing that we will look back on in 10 years and say, ““Whatever happened to it?””. The regulator, the Care Quality Commission, can play a role in that by monitoring independently whether the constitution is being embedded across the National Health Service, whether it is being used in producing results and whether the public are finding it useful. The commission will want to contribute not only to the implementation of the constitution but also to the 10-year review that is provided for in the Bill, as well as the three-year review of the constitution’s handbook—the instructions on how to do it—which at the moment the Bill does not give the commission a role in. We are keen to see a change there. I, too, believe that quality accounts are a useful addition to the field of quality in the NHS. It is terrific to arrive as the quality regulator at a time when the next-stage review of the noble Lord, Lord Darzi, has really swung the focus of the National Health Service on to quality as the organising principle. What is happening is quite interesting. There is now a huge range of initiatives as people respond to the report. Providers are beginning to think about how they can focus on quality; world-class commissioning is focusing on issues of quality; the performance management system and the performance framework through the strategic health authorities and the Department of Health are focusing on quality; the professions, in the work they are doing on service accreditation and revalidation, are focusing on quality; and the Care Quality Commission, as the regulator, is focusing on quality. It is great to have all those initiatives, but they need to be aligned and brought into some relationship with each other to make sure that they are reinforcing each other rather than cancelling each other out. To give an example, health service providers will be publishing their quality accounts annually from July 2010. The Care Quality Commission, as the regulator, will be publishing its first verdicts on the quality of care of providers as part of a process of bringing into registration for the first time all the NHS from 1 April 2010. So within three months there will be two pronouncements on quality, from the providers and the regulator. As the regulator, we will also be publishing on an annual basis a periodic assessment of the quality of care offered by providers. Those three sets of accounts of quality must all be brought together in some way, otherwise we will overload the system and confuse the public. If the public receive a number of different versions of the quality of care being provided by their local hospital in very quick succession, they will ask what on earth is going on. So alignment, which I gather is the technical term being used in the department, is essential. A number of noble Lords have made the point that the public need to be able to understand quality accounts. I am very much of that view. The trial runs I have seen so far are great for the nerdy cognoscenti of quality but not much cop if you are a local user trying to understand what they are all about. We need to decide what quality accounts are there for. Are they there for individual trusts and providers to benchmark themselves against others? Are they there for clinicians to review their own quality? Or are they there as a statement to the public of the quality and services that they are entitled under the constitution to expect? If it is the third point, they need to be readily understood by the public and to be clear and simple. They also need to be reliable. I share the concerns of the noble Baroness, Lady Murphy, about validation of quality accounts. I come from a regulatory background, in environment. It used to be quite entertaining, if not sad, to watch the creativity that individual plcs put into their annual environmental statements. They were exercises in airbrushing out the things that they got completely wrong and talking up the things they had achieved. None of them was comparable, none of them was comparable between companies nor, indeed, comparable across years, so that you could not track a company’s progress in its environmental performance. We run the risk of that happening if we do not have a very good system of auditing quality accounts, much as financial accounts are audited by auditors. Who should do that I do not know. There is a provision in the Bill that the Care Quality Commission can notify a provider of the odd error or omission which it happens to note as it passes by on its regulatory role. However, that does not seem hugely comprehensive. I would be grateful if the Minister could explore how independent validation of quality accounts could be achieved. I was going to talk about piloting direct payments but I fall back in admiration of the magnificent exposition by the noble Baroness, Lady Campbell of Surbiton, of exactly how direct payments can enable and empower people to make sensible choices. One note of caution—I am sure the noble Baroness will tell me later that she heard all this before, when the issue of personalised payments in social care was introduced—is that the experience from the pilots and the subsequent implementation of social care is showing that, for some users of care, personal payments are a godsend, particularly for younger physically disabled users of services. Indeed, it would be a brave person who would deny the noble Baroness, Lady Campbell of Surbiton, with all her resourcefulness, her personal payments. An elderly person with dementia or a person with learning difficulties would need quite a lot of intermediary support to use personal or direct payments effectively. There will need to be clear thought about the role of regulation in this area as we see organisations growing up as intermediaries which may be there with a commercial purpose and a wider range of innovative provision which does not fit neatly into the current management control of the NHS. There are real issues, therefore, but I will not hinder the wish of the noble Baroness, Lady Campbell of Surbiton, for direct payments to be available to those people who can use them as well as she does. It is great to see her back and in good health. Trust special administrators is a ““consenting adults in private”” issue. You have to be an NHS organisational nerd to get excited about it, I am sure. If trusts are failing on quality rather than on financial grounds, I would anticipate that the regulator would need to be involved in advising on the decision. At any rate, once the new registration system is in place for NHS providers from April 2010, any reconfiguration of services under the special administration heading would need to be re-registered with the regulator. That cannot automatically be assumed. The long list of organisations which the Secretary of State must consult, contained in the Bill’s proposed new Sections 65B, 65D and 65P to the National Health Service Act 2006, does not include the Care Quality Commission as the regulator which needs to re-register services. I hope the Minister will consider whether that omission is to be remedied. I welcome the extension of the powers of the Commission for Local Administration in England to cover complaints about privately arranged or funded social care. I have one plea across health and social care. We are seeing a re-shaping of the complaints process within the National Health Service. We are seeing changes in the responsibilities of various ombudspersons. The complaints processes and system are still pretty complex for the average user to penetrate. I do hope we can press the Minister to get a clear exposition of exactly how the wider complaints process in health and social care will work for the future and how it can be readily understood by the public, and that all those involved in the complaints process can help to promulgate information widely across the public domain. On tobacco control, I read one of those heart-stopping statistics recently that nearly 20 per cent of 15 year-old girls smoke. We should take all possible measures to reduce the risks that people face from smoking at an early age. I support the ““point of sale”” measures in the Bill but I would like it to go further, including full removal of tobacco-vending machines, which is where many young people get their cigarettes. I would like that to be not just a possibility in the Bill but for it to be done from the outset. The Bill should also include enabling powers to introduce plain packaging for all tobacco products. Both those remedies—removing vending machines and introducing plain labelling—would be in line with the World Health Organisation’s recommendations. Vending machines have already been removed in more than 22 European countries, so we are not exactly in the vanguard. Simply having an enabling measure in the Bill is not sufficient. I shall press the Minister to go further in Committee. Last but not least, I was a little distracted when I suddenly heard the noble Lord, Lord Naseby, who is no longer in his place, say that the Care Quality Commission had already had its wings clipped. He lives in the next village to mine, and we are both near-neighbours of the Royal Society for the Protection of Birds, of which I am an ex-chief executive. The Care Quality Commission has not already had its wings clipped—as an expert on ornithology, I can vouch for that. Indeed, we are flapping with vigour in preparation for taking off on 1 April to ensure better care for people.