Care Bill [Lords]

Stephen Dorrell Excerpts

Monday 10th March 2014 Commons Chamber

[Paul Burstow]

This part of the Bill and this group of new clauses and amendments are all about ensuring that the system delivers the best possible quality of care and that, when things go wrong, it is clear how the situation is to be corrected and what penalties will be faced by those who have let people down and, in some cases, treated them in an appalling way. There is much in this part of the Bill that is to be applauded, although the nature of the Report stage of a Bill means that we often do not applaud a Bill much, because we are focusing on the things that we want to amend further.

New clause 8 deals with a subject that was also a feature of our discussions in Committee—namely, the concern that the commissioning role of too many local authorities, and the discharge of their responsibilities for planning for the care and support needs in their communities, had degenerated into little more than crude procurements and, worse still, in some cases just spot purchasing of care services. In some local authorities, there was no sense of strategy or of engagement with the local population, and there were no pragmatic conversations with provider organisations ahead of a procurement process. There was no real sense of how to shape the market to deliver the best possible outcome from the point of view of the wider public interest.

Those concerns were expressed a number of times in Committee, and they have been echoed throughout all the stages of the Bill. They were certainly strongly expressed by a number of the representative bodies of provider organisations when they gave evidence to the Joint Committee scrutinising the Bill. Of all the evidence sessions in that Joint Committee, the one that sticks with me is the one at which the provider organisations gave evidence. There was a palpable sense of the deterioration, and even the collapse, of relationships between local authorities and providers as a consequence of the commissioning not being done well in some organisations.

My new clause is designed to address a concern expressed by a number of organisations about a change that the Government made to the Bill in the other place. In that change, they removed from the legislation that established the Care Quality Commission the provision for periodic reviews of the performance of local authorities in regard to their statutory duties on care and support. I am prepared to accept the arguments that the Minister made before removing that provision, but only if we can have much greater certainty that the Care Quality Commission will undertake regular thematic reviews of care and support services.

New clause 8 sets out a number of the things that I think such a thematic review should include. For example, we have established a regime for sector-led improvement whereby local authorities can seek peer review of their delivery of quality commissioning of care and support services. It is working well in some places, but there is certainly evidence that it is not in others. There is a concern that arrangements will be made that allow an inadequate level of peer review and, frankly, people to get away with not doing the right thing. That is why a back-stop provision allowing thematic reviews is absolutely essential, and why ideally I would like the CQC to be independent in its judgment on that, rather than beholden to Ministers to authorise it. That is not the situation we are in, but the new clause would have us look at those issues.

I was told by a provider that I met at an event which the United Kingdom Homecare Association organised with me that CQC inspectors positively discourage comments about local authority commissioning. If a provider has a concern about how they are being constricted, arguably inappropriately, by a commissioner’s decision or practice and tries to raise that with an inspector, they are told, “That is not a matter for us.” It is absolutely a matter for the CQC. I hope the Minister can say something about what he will say to the CQC on that issue. It seems to me that understanding the intervention of commissioners is a really important part of gathering intelligence about the robustness of a local care economy, and the best way to gather that intelligence, at least in part, is by inspectors being open to being told about that.

[Mr Stephen Dorrell (Charnwood) (Con)]

Does my right hon. Friend agree that it is a matter of not only looking at how competently a local authority commissioning process is commissioning the service as we know it, but thinking beyond that and enlarging the role of commissioning in changing the balance in the system of care delivery?

[Paul Burstow]

Absolutely. That is why the duty on market shaping set out in the Bill is about stretching the local authority to take that wider population-level interest, and not only for the people for whom they will arrange care and for whose care and support needs they will pay, but for the whole population who might need care and support but will be funding it themselves. I do not see how local authorities can satisfactorily discharge that new and important responsibility if there is not also a fairly critical examination of commissioning practices themselves. That is why I have tabled the new clause.

--- Later in debate ---

[Nick Smith]

My hon. Friend has got to the nub of the issue. Managers and directors of organisations such as care homes have to accept that they set the culture of those places, and that they are responsible for looking after the residents in their care, and for avoiding neglect and abuse. If they get it wrong, they should face the possibility of a jail sentence. That is what the new clause would do.

We must go that extra mile to ensure that our safeguards deliver for care home residents. New clause 27 would greatly help that cause. I intend to divide the House on the measure.

[Mr Dorrell]

I want to speak primarily to the new clauses moved by my right hon. Friend the Member for Richmond, but first I wish to comment on the speech by my hon. Friend the Member for Bristol North West (Charlotte Leslie), who has been a consistent advocate of the importance of ensuring that we have a culture in our health and care system that creates space for whistle- blowers, not because we want a world full of whistleblowers, but because we want an open culture—as she rightly says—in which the whistleblower is redundant.

The example often cited in this area comes from the US Navy. A junior rating prevented flying from an aircraft carrier because he was concerned about a safety element. As it happened, the concern was misplaced, but the rating was celebrated because he had the courage to raise it. The culture of the ship was such that it allowed that individual to take the steps necessary to cover the risk. In a sense, the story is most telling because the concern was misplaced but the individual was celebrated for having had the courage to take action. That is the kind of culture that we should have in the health and care system.

I do not agree that we need a candour commissioner: it is part of the core function of the Care Quality Commission’s inspections of health and care provider institutions to make an assessment of whether that culture exists in an institution. If that culture does not exist, it is hard to see how that institution can deliver the standards of care that we would all want to see.

My main reason for speaking is to pick up the points raised by my right hon. Friend the Member for Richmond—

[Paul Burstow]

Sutton and Cheam.

[Mr Dorrell]

Forgive me—the right part of London, but the wrong constituency.

My right hon. Friend is on to an important point and I shall listen with care to what the Minister has to say in reply. We have been arguing for the best part of a quarter of a century about the role of commissioners, not just in the social care sector but across the health and care sector. As my right hon. Friend said, in different parts of the Health and Social Care Act 2012 this commitment to what is, in the jargon, called integration, but what I prefer to call joined-up services, is introduced into different parts of the system. Rightly, my right hon. Friend wants to include it in the terms of reference of the Care Quality Commission, but we need to think beyond just introducing it as an add-on into bits of legislation, the prime purpose of which lies elsewhere.

In my view we have no choice—and I do not particularly want a choice—but to create a health and care system that puts more emphasis on prevention, on community services and on joining those services to the rest of the health and care provider network. For a quarter of a century we have been seeking, rather spasmodically and under Governments of all political complexions, to build a commissioner system charged with delivering that type of care system. Ministers need to rise to the challenge of showing how we move from where we are today towards a commissioning system that is fit for purpose to deliver that type of care outcome. The system that we operate is often described as fragmented, and we all know that different parts of the system are indeed fragmented. But the fragmentation is worst in the commissioning institutions. We have social service authorities that are responsible for commissioning social care, and in the next sentence of our speeches we say that that is the same thing as community services, but those are commissioned by CCGs. In the next breath, we say that community health is the same as primary health, but that is commissioned by NHS England. As they say in the modern jargon, “Talk me through it.” How do we deliver properly joined-up services if the people responsible for commissioning the service are so fragmented?

[Paul Burstow]

My right hon. Friend is making a very important point, which he has pursued vigorously as Chair of the Select Committee. Does he agree that part of the evolution that needs to take place is an extension of the role that we originally envisaged for health and wellbeing boards, so that they become the place where these matters come together? The default should be changed to one that presumes integration and joined-up services, rather than the other way around.

[Mr Dorrell]

I agree with the thought that my right hon. Friend identifies. I have been choosing my words with care—I hope—in inviting the Minister to chart a course towards a more joined-up concept of commissioning. Almost as I offer my critique of the commissioning structures, I can feel officials in the Box writing the next version of the legislation that will have another go at providing the perfect solution to deliver something that is better than we have ever dreamt up before. I emphasise that what I am looking for from the Minister is a route map or journey—a process, not an event—and preferably one that builds on existing institutions rather than committing what I regard as the mistake of starting again with a clean sheet of paper.

[Grahame M. Morris]

The idea that the right hon. Gentleman propagates, which he has long held—that fragmentation is a bad thing and integration and joined-up services are a good thing—is one that I subscribe to, but does he share my concerns at reports that the commissioning functions through the clinical commissioning groups are to be privatised? Is that likely to make for more joined-up services or greater fragmentation?

[Mr Dorrell]

The hon. Gentleman knows that I do not entirely share his concern about who holds the share certificate for a particular service. I am more concerned about the accountability of a public authority for the use of public money to deliver a public service. On that, the hon. Gentleman and I are probably as one. I am also concerned that the system, from the perspective of the patient and service user, does not rely on them finding their way under their own steam through an impenetrable morass, but is designed with their needs and instincts in mind. That is a test that our current system simply does not pass and has not passed for many years.

[Mr Tom Clarke]

The right hon. Gentleman speaks with enormous authority on these matters. On the issue of community care, does he agree that for many years we have talked about joint planning, which is essential if community care is to be delivered? Does he feel that, even with the Bill and the proposed new clauses, the commission would have sufficient authority to ensure that it works as efficiently and sensitively as the House would expect?

[Mr Dorrell]

No, I do not believe that simply empowering the Care Quality Commission to go into that space is the answer to the question that I am posing. My right hon. Friend the Member for Sutton and Cheam (Paul Burstow) is closer to the right answer in identifying the health and wellbeing board at a local level as the beginnings of an organisation that can deliver a more joined-up commissioning process, joining up the social care system, the community health system, the primary health system and, of course, the hospital service—and I always add the social housing people. In a properly joined-up service, they would focus their attention on the needs of the individual patient service user—an awful piece of terminology; we cannot work out precisely what to call them.

I wish to highlight a bit of institutional tension. My right hon. Friend the Member for Sutton and Cheam proposes that this is a function for the CQC, but I am not entirely convinced. A tension underlying several contributions this evening relates to whether the CQC is the regulator of a provider, or an organisation with responsibility for charting the course, which I am looking for from the Minister, towards a new form of commissioning. The CQC has a full job to do responding to some of the things that my hon. Friend the Member for Bristol North West was talking about—culture and service quality on the provider side—and I am not persuaded that trying to manoeuvre it into the space of developing the kind of joined-up commissioning service I am describing is the right answer to that question.

[Norman Lamb]

I reassure my right hon. Friend that I want to chart the course with him. I completely agree on the need to bring commissioning together. The better care fund is a good nudge in the right direction, but we need to go much further in due course.

[Mr Dorrell]

I am grateful to the Minister for his encouragement that I am on the right path.

There is a serious question here. I agree with my right hon. Friend the Member for Sutton and Cheam that, at a local level, the health and wellbeing board is the organisation best placed to move forward with the process of more joined-up commissioning. How we, as MPs, satisfy ourselves that this is happening to the required standard, with the required levels of economic efficiency across the system as a whole and above the level of the health and wellbeing board, is one of the questions left unanswered by the institutions we currently have. I am not entirely persuaded that the CQC should be encouraged into what I regard as a vacuum.

[Mrs Lewell-Buck]

I will speak to amendment 19 and echo some of the excellent comments made by my hon. Friend the Member for Copeland (Mr Reed).

Amendment 19 would reinstate the Care Quality Commission’s duty to inspect the commissioning of adult social care services by local authorities. The case for the amendment is very simple: the quality of commissioning has a huge impact on the quality of care that people receive. It is extremely important that our adult social care system includes checks to ensure that commissioning is of a high standard. At present, this is not the case.

The current model of sector-led improvement introduced by this Government in 2010 leaves it to local authority peer reviews to identify failure. In practice, this means that neighbouring authorities that already work in close collaboration inspect each other, but only when a neighbouring authority volunteers for inspection. Of course, local authorities that are confident in their commissioning practices are happy to volunteer themselves for scrutiny, but what about those that do not volunteer? It is surely those authorities that we should be most concerned about, yet under the current system they are not subject to proper oversight. Worryingly, the majority of authorities have not been assessed under the peer review scheme. In total, 127 local authorities have not had their commissioning reviewed since 2010. We would not allow this type of reckless leniency with any other service that looks after our most vulnerable. I am certain that it should not continue.

It is clear that when it comes to inspecting local authorities’ commissioning practices, some uniformity and impartiality are needed. The CQC is best positioned to carry out that duty. Certainly, the chief executive of the CQC thinks so, commenting that he has not

“spoken to any national provider association who doesn’t think councils should be inspected”

and believes that

“the removal of that power from CQC was seen as a retrograde step”.

When this proposal was raised in Committee, the Minister insisted that it was unnecessary. He argued that CQC inspection of providers could identify patterns of poor commissioning that would be grounds for a special review.

--- Later in debate ---

[Grahame M. Morris]

My right hon. Friend has hit the nail on the head, because there has been a catalogue of mismanagement. What we need to do if we believe in the importance of such a database is to ensure that we rebuild public trust. The Government have an opportunity to do that, but it will not be a simple matter. We have to look carefully at the implications of what the Government propose and give the necessary assurances.

The assurance that the official gave to the Health Committee had a gap that a coach and horses could be driven through. Several multinational companies could get round it by establishing a subsidiary based in the UK that would have access to the data, if that were the only safeguard.

[Mr Dorrell]

I want to return to a theme that we were discussing in an earlier debate this evening. The true nature of the hon. Gentleman’s concern is unclear. If his concern is that sensitive patient information should be made available only on the basis that the identity of the individual can never be traced and the data remain properly anonymised and confidential, I think that concern would be shared on both sides of the House. But is that his real concern, or is it that the information might be used by a private sector body for the purpose of improving the delivery of health care? I am not clear, provided that the information is anonymised and patient identity is properly secured, what his objection could be.

[Grahame M. Morris]

I thought I was being fairly clear. In the debate on the earlier group of amendments, we discussed the privatisation of the clinical commissioning function. My concern is that that would lead to greater fragmentation, not greater co-operation. On data sharing, I think it was my hon. Friend the Member for Leicester West (Liz Kendall) who gave the example of a questionnaire she was asked to fill in by her GP, which contained questions relating to alcohol consumption, smoking and so on. If that information was made available to a private health care company and, as a consequence, premiums were increased, people would have concerns. The Minister said that that has been ruled out and that it would not happen, but it is an example of why such concerns have been raised.