My Lords, I declare an interest as a chair of a NHS foundation trust and as a consultant and trainer with Cumberlege Connections. I am happy to support my noble friend Lady Pitkeathley’s Amendments 74 and 75, which rightfully push the CQC into the direction of integration of services. I also sympathise with the amendments of the noble Baroness, Lady Greengross, Amendments 76ZZA and 76ZAA, to which she will speak later.
My Amendments 74A, 76ZA and 76ZB and my opposition to Clause 80 stand part go to the core of the purpose of CQC and its approach to performance assessment in health and social care. Inevitably, recent events at that regulator in relation to Morecambe Bay and before that at Mid Staffordshire will readily come to mind. There can be no doubt that the current leadership of CQC faces a major challenge in changing the culture of the organisation and its approach to inspections. It has much to do to restore both public confidence and confidence within the NHS about the way in which it operates. That is why this clause is so important.
Clause 80 substitutes Section 46 of the 2008 Act and provides that the CQC’s duty to conduct periodic reviews, assess performance and publish reports of such assessments, which are henceforth to be known as “ratings”, is to apply in respect of any regulated activities and any registered service providers as may be prescribed in regulations. In addition, where regulations so provide, the CQC must also review and assess the performance of the provision and commissioning of adult social services by English local authorities. CQC is to be given responsibility for determining the quality indicators against which services and providers will be assessed. This may include measures of financial performance and governance in its assessment if the CQC deems this appropriate. Different quality indicators, methods and frequency in periods may be used for different types of cases. The CQC may also review the indicators of quality and method statement from time to time as it sees fit.
Let me say at once that I support the broad intention of these clauses to make the CQC responsible for rating providers and local authorities. I say again that one should not underestimate the task. It is important
that the CQC is not put under undue pressure to rush to change the way that it operates and to introduce new ratings without proper pilots being done and without having enough time to do it.
I refer the noble Earl to the Nuffield Trust’s work. As he knows, the Nuffield Trust was commissioned to carry out a review for the Secretary of State into the possibility of rating providers of health and social care. It argued that the new ratings must be given adequate time to work together with a range of stakeholders in developing a system which enables both patient choice and professional leadership to drive up standards of quality. That is vital. Yet I am concerned by the document issued by the CQC recently that indicates that it is to start inspecting and regulating NHS acute hospitals, in the ways that it set out in that document, from October 2013. Indeed, from December 2013, it will begin to rate NHS acute trusts and NHS foundation acute trusts, aiming to complete them before the end of 2015.
Have Ministers put pressure on the CQC around the timing of those ratings? Secondly, does the noble Earl not think that there is a risk that the CQC will be forced to rush into a new system without proper consideration? I remind him that the chairman of the CQC has recently made a number of statements. First, he has said that the approach to inspections by the previous leadership was wrong; it was wrong to go for generalist inspections. He also says that the culture of the organisation was wrong. Given that there are about 1,000 people employed by the CQC, although I am not absolutely certain, how on earth is the culture going to change in a short period of three or four months? I just do not think it is going to happen.
I have great admiration for the current leadership of CQC, but the risk is that it is going to be forced into a new system too quickly and it could fall over. As a result, its credibility will be very much damaged. Let us face it; it is almost starting from a negative position. I must confess that I am surprised that such an ambitious timetable has been set.
Who will be assessed? As I have already intimated, the clause provides for the Secretary of State to draw up regulations laying out exactly which services the CQC will rate. They are likely to be hospitals. GP practices, care homes, domiciliary care services across both the public and privates sectors and local authorities. Will the noble Earl confirm that? Will he say why this is not specified in the Bill? Does he not consider it important enough for Parliament to decide which bodies should be assessed, and to do so in primary legislation rather than through regulations?
I asked at Second Reading whether clinical commissioning groups are to be assessed. If not, why not? The Bill allows for local authorities to be assessed for their performance in the commissioning of adult social services, so I cannot really see why NHS commissioners—the CCGs—should not be similarly covered. The same logic then applies to NHS England which, after all, has been given a massive commissioning budget in relation to specialist services. If it is appropriate for local authorities to be assessed for their commissioning responsibility, surely all health commissioners should
be similarly assessed. That must apply to NHS England because otherwise I do not see who will hold it to account for the mammoth amount of resources it will spend on commissioning specialist services.
I am particularly interested in local authority assessment, particularly in the way that services are commissioned. Can the noble Earl tell me whether this is intended to be a priority for the CQC? He will know that there is real concern about the practices of many private sector providers in social care in using zero-hour contracts and allocating only 15 minutes with each client. It is vital for the CQC to be able to investigate the way in which local authorities commission those services. We will come to this in Clause 5 but it would be very useful if the noble Earl could confirm that the commissioning responsibilities of local authorities will be a priority for the CQC.
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Turning to the inspection approach and the rating system to be adopted, according to the recent document issued by the CQC:
“Our inspections of hospitals will vary in terms of the things they look at and the time they take, but they will take as long as is needed—typically 15 days, with an average of 6-7 days on site—to make a thorough assessment of the quality and safety of care. In the vast majority of cases, inspections will be longer and more thorough than our current approach of a small team of inspectors being on site for one or two days. Our inspectors will spend more time talking to people who use the service, to staff, senior managers and members”.
That is very welcome. I am sure that that is the right approach. The noble Earl will know that there has been a problem with short-scale inspections, which take just one part of a service and do not really give a measure of the scale of services being provided.
We then come on to the rating of services, which I have raised with the noble Earl. As far as I can see, the intention is to follow the Ofsted approach of rating from 1 to 4, with 1 being outstanding, 4 being a measure of inadequacy, 2 being good and 3 being satisfactory but needing to improve. That is an approach. But the noble Earl will be aware that the Nuffield Trust has argued that,
“the Government and CQC must be alert to the possibility of aggregated ratings which reflect high general standards of care but conceal individual failures within organisations”.
It goes on to say:
“For hospital trusts in particular, which operate across multiple sites and provide a range of complex services in different wards and units, it is important that service-level assessments are easy to find and understand”.
This is very important because the CQC is going to follow the Ofsted example. Outstanding hospitals will be inspected only every three to five years and good hospitals every two to three years. So a hospital could be rated as outstanding and then not inspected for five years. The problem with that is that we all know that services can go up and down and that changes in leadership can have an impact on the quality of an organisation. We know there are examples in education where schools or colleges have been rated 1, have not been inspected for five or six years, and some of them have gone down to 3 or 4.
I am more concerned about the public’s confidence in such a system. Where a hospital has been rated 1, within 1 there will probably be some inadequate services;
if something goes drastically wrong, the whole rating system will come into serious question. What I am asking for is a much more sophisticated, balanced approach to rating these institutions. That is why it would be right that before any substantive programme comes into being there should be pilots, which should be fully assessed. I hope that Parliament would have an opportunity to debate them as well.
Finally, I come to my Amendment 76ZA. My understanding is that part of the criteria which will form the ratings judgment by CQC will be whether staff would recommend their organisation to patients. I am sure that that would be a very valuable component of the ratings. I have been contacted by the Chartered Society of Physiotherapists which says that, perhaps, we should go even further and actually consider staff health and well-being. That seems to make a great deal of sense. Sickness absence in the NHS is a major problem. The sickness absence rate for the winter among healthcare assistants has been very problematic. I do not expect the noble Earl to agree to my amendment, but I hope he will give some comfort that CQC, in looking at the way staff feel about their organisation, might be able to develop some kind of indicator of the way staff are dealt with. Health and well-being might be a very good way to do this.
Overall, we wish CQC well. I am concerned about the pressure being put on it to come up with a new system before it has time duly to consider it. I hope the noble Earl will agree to an amendment around pilots.