Care Quality Commission (Reviews and Performance Assessments) Regulations 2014

Debate between Baroness Barker and Baroness Wall of New Barnet

Monday 27th October 2014 Lords Chamber

[Baroness Wall of New Barnet (Lab)]

My Lords, I support in principle the wording of the business that we are dealing with, particularly the emphasis on regular assessment of other than the provider trusts. I share with the House and the Minister why I now feel that that is even more important. I declare an interest as chairman of Milton Keynes Hospital NHS Foundation Trust. Just last week, we were inspected by the CQC. Obviously, we do not yet know the outcome of that. The CQC was with us for four days and there were 40-odd people there.

As the noble Earl is aware, I have been very supportive of the CQC and share his aspirations for it. To be honest, our inspection was extremely thorough. We have to wait with bated breath for the outcome, but the enthusiasm, what was described as the buzz around the hospital and the way that people felt strongly about the services that they were giving made a huge difference to the whole thing. I am only three months into that trust, but this was not about preparing for the CQC; it was about the culture of the organisation and wanting to improve. I hope that the CQC comes back with recognition of that, whatever the outcome might be.

The inspection was carried out under the new way of doing things, which I think is great. There were many more people across all the spectrums of our services, at a professional and clinical level. That was superb. The reporting back every night was very good and helpful to the chairman and chief executive. All that felt good and thorough, which is what it is all about. I agree with my noble friend’s view about extending that for the very reason that he just gave. The importance of that inspection to the outcome for our patients was absolutely paramount, regardless of what the outcome might be in terms of the grading or level of assessment we might be given. But without that thoroughness and rigour, particularly with the CCGs, who are the ones making decisions about our services, with the GPs who run them—unless there is a deep dive, as we would call it, into any other part of the health service—the gaps that are still a worry for us may remain.

In particular, my noble friend Lord Hunt said that there was an issue around local authorities. All trusts are struggling terribly with A&E. There are many reasons for that, as my noble friend has said. But one of the big reasons is the lack of rigour in social care and local authorities’ commitment to or understanding of the role that they play. From the experience that we have had over the past week, I believe that this is not a threat to people: it is empowering for them to have the CQC in there, ensuring that the rigour that they are supposed to apply to their work is there and that the role they play in patients’ experience really makes a difference. I urge the noble Earl to consider this opportunity yet again. We made a decision in the Care Act, which I think even more now is really a mistake from which we need to move on. I do not share the cynicism of my noble friend, but I share the concern about whether the CQC can embrace all that.

The investigation into my trust was supported, as I understand it, by far more clinicians than ever before and far more people had a much greater knowledge of the health service. If the CQC can continue to develop in that way, I believe it is in its interest—and, more importantly, in our patients’ interests—that those commissioning groups go wider and deeper into other than the provider trusts.

[Baroness Barker (LD)]

My Lords, I spent a happy weekend making a start on the 500 pages of regulations that have been issued under the Care Act. What can I tell noble Lords? I am living for pleasure alone. I regard this Motion as the first of many to come our way.

I thank the noble Lord, Lord Hunt, for the opportunity to go back to some of the discussions that we had during the passage of the Bill, particularly on commissioning. We had long debates about commissioning and the extent to which it did or did not impact on services. We also talked at considerable length about the differences between the commissioning of healthcare in the NHS and commissioning in social care. In these regulations, we are beginning to see some attempt to have proportionate and slightly different attitudes towards commissioning in both those settings. I would like to see us taking a more proportionate look at commissioning across the board. To a certain extent, these are the first of the regulations that begin to do that.

We also had extensive discussion about whether performance ratings should be specific to particular services within hospitals or whether they should go across the piece. My recollection, informed quite often by people with valuable experience such as the noble Baroness, Lady Wall, was that there would be a lot of data generated in hospitals, particularly clinical governance data, which would be there to inform one’s opinion about a particular service in a hospital. However, what would have been missed, and what was missed so spectacularly in Mid-Staffordshire, was the across-the-board bad management practices throughout a hospital that undermined patient care. That was why we ultimately took the decisions that we did about the nature of performance review.

I want to pick up two particular issues that are brought to the fore by these regulations. I notice that prison healthcare has been exempted. I understand that there is a sense in which the NHS or the CQC would be able to look at the performance of only a part of prison healthcare. But prison healthcare is, in terms of mental health, addiction services and so forth, becoming much more important. There is a much clearer focus on the amount of ill health that people have within the criminal justice system. I want to be sure that we are not enabling those prison health services to escape proper scrutiny.

My final question to the noble Earl is more fundamental. We had extensive debates during the passage of the Care Bill about the right of entry for those people who are involved in carrying out performance reviews and the extent to which the people responsible for them should be able to go into any service to assure themselves that those services are safe and the people within them are not being abused. I do not see anything in these regulations that gives comfort to those of us who believe we took the wrong decision during the passage of the Bill and that, as a consequence of our failure, there may well be people in health and social care settings who are being abused at worst or ill treated at best.

[Baroness Wall of New Barnet]

I thank the noble Baroness for giving way. In response to her comments on nurses and hospitals, she is absolutely right. I emphasised the clinical stuff. However, the CQC interviewed everyone on our board: the non-executive directors, me—as chairman—for an hour and a half, and all our executive directors. It interviewed not just the clinical staff but the whole of the trust to make sure that we all understood what we were doing in the job we are employed to do.

[Baroness Barker]

I thank the noble Baroness for that. I trust that if the CQC was doing its job, it would really go to the seat of power in a hospital and interview the porters.

Care Bill [HL]

Debate between Baroness Barker and Baroness Wall of New Barnet

Tuesday 9th July 2013 Lords Chamber

[Baroness Barker]

My Lords, I wish to speak to Amendment 82A, which is in my name in this group, and to support the amendments in the name of the noble Baroness, Lady Greengross. For well over a decade, we have had evidence that the recovery rates for people being discharged from hospital during the week, through to people being discharged on Friday, vary enormously. There has been evidence in abundance for the past decade that the failure to integrate care plans for people leaving hospital with community services leads to their readmission into hospital as an emergency—and in some cases, to their death. All the factors that contribute to that should not be news to anyone who has ever read about delayed discharge.

At the heart of our failure to really look after older people who go in and out of hospital is not just the failure to carry out assessments at the proper time but the failure to share that information with all the relevant people along a care pathway. It has been interesting, particularly over the past year, to begin seeing something of a change taking place both in health and social care. One of the driving factors behind that are the shared outcomes frameworks to which health, adult social care and mental health now have to work. The fact that we have the five overarching domains and that each of them is working to performance indicators below them is beginning to have a real influence, not just on high-level strategic planning but on front-line work.

We have always known that there have been excellent examples of integrated care. Where care works well, it works fantastically well and where it does not, it is just a disaster. The trouble is that we can never really pinpoint and identify where that will happen, other than that the systems that work well are always those which have the patients at their heart, involved in the planning process as well as being recipients of care.

My Amendment 82A is prompted, as I think noble Lords will know from last week, by the Christian Scientists—the people who, as part of their belief system, wish it to be known that their care should not involve medical treatment because that is incompatible with their beliefs. Beyond that small group of people, whose beliefs I do not share, it is important to register in all this that when we are building systems that assess the needs of older people there has to be within them a point at which older people can dissent, particularly if quite forceful medical decisions are being made about their care. Sometimes we get incredibly enthusiastic in our support of doctors and manage to let that take things over completely.

The noble Baroness, Lady Greengross, has highlighted the key points that we need to focus on because, at the end of the day, integration depends entirely on all the different care providers in the pathway working to common information. If we cannot start now to develop those systems, we will not achieve what has proved for so long to be that elusive solution to integrated care.

[Baroness Wall of New Barnet]

My Lords, I also support all these amendments, particularly in relation to the previous discussion of getting older people out of beds that they are blocking, as I think the noble Baroness, Lady Greengross, put it. That is perhaps an inappropriate word but, in reality, those are the facts. The care plan that everybody has talked about is important, and hugely effective when it works. I have to admit that in my own hospital—I declare my interest as chair of Barnet and Chase Farm Hospitals Trust—it does not always work. Very often, the breakdown with the local authority can come from the start of the agreement on a care plan—what will happen to the individual, how many X-rays they will have, where they will go at the end and so on.

One of the good things in the new system—there are several—is the CCGs. The relationship between clinical commissioning groups and local authorities is proving, in the very short time that it has been working in my area, effective. The more pressure on commissioners in terms of getting hospitals running better, the more interest they have in making sure that local authorities are doing their bit as well. That partnership, in my view and my experience of the past months, has been working much better, which, for us, is a very good thing.