Health and Social Care Act 2008 (Regulated Activities) (Amendment) Regulations 2011

Baroness Williams of Crosby Excerpts

Monday 31st October 2011 Grand Committee

[Baroness Jolly]

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?

[Baroness Williams of Crosby]

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.

[Earl Howe]

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.