New Clause 2 — Care and Quality Commission reviews and performance assesments

Prayers – in the House of Commons at 10:00 am on 9 January 2015.

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‘(1) Section 46 of the Health and Social Care Act 2008 (health and adult social care services: reviews and performance assessments) is amended as follows.

(2) For subsection (3) substitute—

“The assessment of the performance of a registered service provider is to be by reference to whatever indicators of quality the Commission devises, but must include indicators of the safety of health and social care services.”’—(Sir William Cash.)

Brought up, and read the First time.

Photo of Eleanor Laing Eleanor Laing Deputy Speaker (First Deputy Chairman of Ways and Means), First Deputy Chairman of Ways and Means

With this it will be convenient to consider:

New clause 3—Care and Quality Commission annual State of Care Report

‘(1) Section 83 of the Health and Social Care Act 2008 (health and adult social services: reports for each financial year etc.) is amended as follows.

(2) After subsection (2) insert—

“(2AA) The reports under subsection 1(b), (c), and (d) must, in particular, cover the safety of health and adult social care services in England.”’

Photo of Bill Cash Bill Cash Chair, European Scrutiny Committee, Chair, European Scrutiny Committee, Chair, European Scrutiny Committee

Before I make my remarks on the proposals, I pay tribute to my hon. Friend Jeremy Lefroy, my neighbour, with whom I have worked for the past five years with great enthusiasm, because he has dedicated himself to all matters in his constituency, but specifically to dealing with the problems that came out of the Mid Staffordshire public inquiry—I campaigned vigorously to get that public inquiry. I also pay tribute to Ken Lownds, whom I regard as a hero of that inquiry in many respects. I pay tribute to his work on zero harm and the Bill. I do not in any way want to leave the Minister out of the tributes because he has done a great job, as has the Secretary of State for Health. I wanted to put that on the record. We are reaching the climax of the Bill and this is the moment to pay tribute to those who so richly deserve it.

The object of new clause 2 is to amend section 46 of the Health and Social Care Act 2008. The section deals with health and adult social care services reviews and performance assessments. It comes under the rubric of reviews and investigations under chapter 3 of the Act on health care standards.

Section 46, “Periodic reviews”, provides that:

“In respect of each Primary Care Trust the Commission”— the Care Quality Commission

“must…conduct reviews of the provision of health care provided or commissioned by the Trust…assess the Trust’s performance following each such review, and…publish a report of its assessment.”

It also makes special provision with respect to each English national health service provider. Subsection (3) states:

“In respect of each English local authority the Commission must…conduct reviews of the provision of adult social services provided or commissioned by the authority…assess the authority’s performance following each such review, and…publish a report of its assessment.”

In the light of experience, and to improve the 2008 Act, particularly section 46, the new clause would substitute for subsection (3) the following:

“The assessment of the performance of a registered service provider is to be by reference to whatever indicators of quality the Commission devises, but must include indicators of the safety of health and social care services.”

The purpose of that is to require the CQC to ensure that the indicators used to assess ratings cover the safety of care, which goes back to the question of harm-free provision. Basically, the argument goes like this: the object is to stress that the CQC can be an effective regulator only if it is free of undue influence from Ministers. The measure is a good indicator of whether the Government are prepared to say that they want the CQC to be able to exert influence and carry out its functions irrespective of undue influence from Ministers. In other words, are they prepared to step back and allow the CQC to do its job properly?

The CQC has decided to make safety one of the key indicators for the assessment of provider ratings. As a result, safety is a critical component of the CQC’s new inspection regime. On many occasions, I have discussed with Ken Lownds over dinner and otherwise the origins of much of his thinking on the subject, some of which I had difficulty understanding—apparently some of it comes from aviation safety, but I will leave that to the experts.

Under the leadership of the three chief inspectors, the CQC has put in place specialist inspection teams able to scrutinise the quality and safety of care more rigorously. Inspections no longer simply consider whether providers are meeting the registration requirements, but provide a judgment about the quality of care on a scale running from outstanding to inadequate, offering providers, commissioners and local people fuller information about the quality of care.

The CQC’s tougher, people-centred, expert-led and more rigorous inspections are seeing some outstanding care, and the CQC has already rated many good services. That new approach has also exposed poor care and variations in care, making the level of quality transparent in a way it has never been before.

I have to say that my experience of what happened after Mid Staffordshire—this was before my hon. Friend the Member for Stafford came into the House, and I pay tribute to what he has done to help me since—was itself a matter of the gravest concern. Having witnessed what went on there, I then had to engage in a campaign, and I tried, unsuccessfully, to push the Government of the time into having a public inquiry, but Ministers, including two Secretaries of State, refused point-blank to hold one.

Furthermore, I had to nudge—if I can use that word—those on my own party’s Front Bench quite vigorously. I think that would be the appropriate description. That included our then shadow Secretary of State and the now Prime Minister, who responded magnificently, making an inquiry a manifesto commitment. One of the very first things the Government did when they came into power under the present Prime Minister was to say, “We will have this Mid Staffordshire public inquiry under the Inquiries Act 2005.” As a result of that and of the work of Ken Lownds, my hon. Friend and others of us who have been involved in this issue, including the sponsors of the Bill—I should also refer to them—we now have this new Bill in my hon. Friend’s name, which will make quality transparent in a way it never has been.

We are already confident of the great strides the CQC is making to be an effective regulator of health and social care providers. I hope that the Minister will accept that new clause 2 is exploratory, but I tabled it in the fervent belief that he will respond satisfactorily to my request, because this is a matter of grave concern.

If it is convenient, Madam Deputy Speaker, I will move on to the next new clause, unless my hon. Friend the Member for Stafford would like to respond to my points now. Would that be appropriate?

Photo of Eleanor Laing Eleanor Laing Deputy Speaker (First Deputy Chairman of Ways and Means), First Deputy Chairman of Ways and Means

At this point, we are considering new clause 2 and new clause 3, so it would be appropriate for the hon. Gentleman to address new clause 3, if he so wishes.

Photo of Bill Cash Bill Cash Chair, European Scrutiny Committee, Chair, European Scrutiny Committee, Chair, European Scrutiny Committee

That is very good. I just wondered whether my hon. Friend wanted to respond on new clause 2 before I move on to new clause 3.

New clause 3 proposes to amend section 83 of the 2008 Act, which deals with health and adult social services and with reports for each financial year. The new clause would insert proposed new subsection (2AA), which says:

“The reports under subsection 1(b), (c), and (d) must, in particular, cover the safety of health and adult social care services in England.”

To put that into ordinary language, the purpose is to require the Care Quality Commission to cover safety of care in the annual state of care report. That is hugely important, because it is the narrative to which people will be able to refer in identifying progress on these incredibly important provisions.

The object of the exercise, as I understand it, is that the CQC’s annual report should cover safety issues. The most recent state of care report, published in October, already does, but it is not currently a statutory requirement. That would be the case if the Government were good enough to agree to the new proposals. It is difficult to conceive of circumstances in which the CQC’s annual report would not cover the safety of care provided by the organisations it regulates. Indeed, a report that did not address this area could amount to a failure by the CQC to discharge its functions. Where that is the case, section 82 of the 2008 Act gives the Secretary of State the power to direct the CQC on how to discharge its functions.

There we have it: both new clauses are a really important move to improve greatly the movement, proposed under the Bill, towards harm-free care in the health service; the direct result of the enormous progress made by the Government in relation to the outcome of the Francis report. I pay tribute to Sir Robert Francis, the chairman of the inquiry, for his very powerful help in all these matters over the years. It has been a tremendous but very difficult experience to be in the front line of the disaster and tragedy that occurred at Stafford hospital. The most important thing is that we should learn the lessons. We have done so and the Bill is an exceptionally good demonstration of that. Above all else, it will help the people—not just those in our constituencies—who have been affected. The Mid Staffordshire public inquiry and report can now be translated into national legislation through this Bill, introduced by my hon. Friend the Member for Stafford, which could not be more appropriate, relevant or significant.

I offer sincere thanks to my hon. Friend, to Ken Lownds, the Minister and all the officials who have played such an active part in ensuring the Bill’s success.

I wish it well on its way. It will make an enormous difference to health care throughout the entire national health service.

Photo of Jeremy Lefroy Jeremy Lefroy Conservative, Stafford 10:15, 9 January 2015

I would like to speak to new clauses 2 and 3 together. The new clauses tabled by my hon. Friend Sir William Cash seek to embed safety as the central component of the CQC’s inspection regime. My hon. Friend is not only a supporter of the Bill but a major inspiration behind it. His determination in this place to establish what went wrong in the care of his constituents and mine, and to ensure that our NHS was improved as a result, is a major reason for us being here today.

I agree entirely with the principles contained in the new clauses. New clause 2 would place a duty on the CQC to include safety in its annual performance assessment and ratings, while new clause 3 would require the CQC to consider safety in its annual state of care report. I believe that clause 1 of my Bill would already ensure that the CQC has a duty to do all that is contained in new clauses 2 and 3. I will try to explain why.

Clause 1 states that the requirements for registration with the CQC will always cover safety by securing that registered providers of health and social care “cause no avoidable harm”. The CQC will therefore be under a duty both to consider safety in its inspections and ratings and to cover this area in its state of care report. Indeed, it already does so, and here I pay tribute to the previous Government for introducing this annual state of health and social care report through the 2008 Act.

The foreword to this year’s report, to which my hon. Friend the Member for Stone has already referred, is hard hitting about safety and indeed quality. It states:

“The variation in the quality and safety of care in England is too wide and unacceptable. The public is being failed by numerous hospitals, care homes and GP practices that are unable to meet the standards that their peers achieve and exceed.”

I welcome this candour. This is what we expect from the CQC—to hold the NHS and indeed the Government to account, and to ensure that action is taken.

Let me mention an article that appeared in The Timesyesterday, showing the huge variability of standards within the NHS and praised some outstanding trusts, specifically mentioning one in Birmingham and a couple of others. What we want to see is those standards being uniform across the NHS. I know that all those working within the NHS and social care want to see that. Nobody goes into work wanting to fail; they want to succeed for their patients to whom they have a duty of care. For our part, it is our responsibility to ensure that they have the environment in which that can happen. That is a small part of what this Bill is designed to bring about.

Photo of Bill Cash Bill Cash Chair, European Scrutiny Committee, Chair, European Scrutiny Committee, Chair, European Scrutiny Committee

I recall the extraordinary experience of discovering that in order for the original trust in Mid Staffordshire to achieve trust status, an interview was necessary. In that interview, I believe 48 questions were put, 35 or so of which were about finance—not about care and safety. That demonstrated why everything went wrong. Now, however, under these arrangements, the whole situation is completely reversed, which is a thoroughly good idea.

Photo of Jeremy Lefroy Jeremy Lefroy Conservative, Stafford

I entirely agree. There were moves towards that when the Healthcare Commission, which was responsible at that stage and manifestly failed in the case of Mid Staffordshire, was replaced by the Care Quality Commission—an understanding by the previous Government that progress needed to be made in ensuring the quality and safety of care. That progress has been maintained and accelerated under the present Government.

I was referring to the 2013-14 report. One of my hon. Friend’s new clauses specifically provides that safety should be a part of such reports. Indeed, the report goes into detail over the way in which the CQC has inspected for safety. On page 12, for instance, it gives an example of a wide variation in the ratings on safety and four other measures—effective, caring, responsive and well led—for each department in a particular hospital. The ratings for safety range from inadequate to good, which shows that even within a trust or a hospital, there is a wide range of safety performance. The CQC is therefore already fulfilling what my hon. Friend is seeking in these two new clauses.

Of course, the same might be argued for clause 1 itself: why is it necessary when the CQC is now implementing the Secretary of State’s requirement to ensure that providers “cause no avoidable harm”? The reason is that, without clause 1, a Secretary of State would not have that obligation. While I cannot imagine a Secretary of State who would not consider safety and “no avoidable harm” as top priorities, experience and indeed the CQC’s own report from which I have quoted show that some of the organisations for which the CQC has the responsibility for regulation have not, and might still not, take safety seriously enough.

Photo of Bill Cash Bill Cash Chair, European Scrutiny Committee, Chair, European Scrutiny Committee, Chair, European Scrutiny Committee

I distinctly remember insisting over and over again during the debates on the whole question of Mid Staffordshire that were taking place until the last general election that it was the Secretary of State who had to take the final responsibility for these matters, and that the duties imposed on him and the functions that he had to perform had ultimately to be his and must not be transferred to some other agency, however worthy it might be and however hard it might work to achieve objectives which, as we now know, were not being complied with satisfactorily, but which are being complied with satisfactorily now, under the Care Quality Commission. The argument that my hon. Friend is advancing comes straight from the history of the experience of Mid Staffordshire, and there is no one better to put the case than him.

Photo of Jeremy Lefroy Jeremy Lefroy Conservative, Stafford

I thank my hon. Friend for what he has said. I entirely agree that this is an extremely important matter. Clause 1 will ensure that there is no slippage in the future, because the Secretary of State cannot get out of her or his responsibility, and the Care Quality Commission’s annual state of care report will be part of the process of holding the Secretary of State to account. I encourage, indeed challenge, this or any future Government to hold a proper annual debate on the report, because it is a vital report. Indeed, I should welcome a debate on the 2013-14 report, uncomfortable thought it might be for certain people.

I believe that new clauses 2 and 3 are unnecessary, because what they prescribe flows from clause 1. However, I am most grateful to my hon. Friend the Member for Stone for tabling them.

Photo of Jamie Reed Jamie Reed Shadow Minister (Health)

I listened closely to Sir William Cash. As I said earlier today, and on Second Reading, in Committee and throughout the passage of the Bill that became the Care Act 2014, patient safety is our guiding principle, and we are responsible for ensuring that all that we do is intended to improve it. The purpose of NHS regulation should always be to improve safety and achieve better patient outcomes. I therefore strongly sympathise with the principle of the new clauses. However, I should be grateful if the hon. Member for Stone explained why he does not agree with Jeremy Lefroy that the duties for which they provide are already covered by the Bill and by other legislation.

A little over 12 months ago, I was a member of the Committee that scrutinised the clause in the Care Act that amended the Health and Social Care Act 2008, which new clause 2 seeks in turn to amend. The new clause adds the following words:

“The assessment of the performance of a registered service provider is to be by reference to whatever indicators of quality the Commission devises, but must include indicators of the safety of health and social care services.”

That is sound in principle, but it seems to me that it would remove from the CQC the flexibility that allows it to exercise its own judgment. Existing legislation gives the CQC a duty to describe and justify its indicators, and to consult on them before carrying out inspections. As the hon. Gentleman said, the Care Act also gives it a power to amend and revise those indicators.

Section 3 of the 2008 Act states:

“The main objective of the Commission in performing its functions is to protect and promote the health, safety and welfare of people who use health and social care services.”

Will the hon. Gentleman explain why he thinks his new clause is needed on top of that, and in combination with the CQC’s duty to consult on the indicators that it uses to assess services? If we support the principle of independent inspection, we need to guard against making unnecessary changes to legislation that could deter the CQC from performing its central role of ensuring the safety of the services that is inspects.

New clause 2 requires the CQC to

“include indicators of the safety of health and social care services.”

We all want the best and most effective legislation to be passed, but I fear that the new clause could be open to significant misinterpretation. The section of the 2008 Act to which the new clause relates concerns CQC reviews of the performance of service providers. The CQC will inspect a number of different services, including services that do not directly involve social care. The new clause, however, could require it to include indicators of safety in social care services regardless of whether the service concerned involves social care. If that is the hon. Gentleman’s intention, will he explain why he believes the provision to be necessary? Furthermore, new clause 2 refers to “social care services”, whereas new clause 3 refers to “adult social care services”. I hope that the hon. Gentleman will be able to explain what appears to be a discrepancy.

As Labour Members have made clear, we believe that patient safety is paramount in our NHS, that effective regulation is key to securing it, and that producing such regulation is our role in the House. I should be grateful if the hon. Gentleman explained why he believes that his new clause is essential to more effective regulation, given that—as the hon. Member for Stafford has pointed out—it seems merely to repeat existing provisions.

Photo of Daniel Poulter Daniel Poulter The Parliamentary Under-Secretary of State for Health

I thank my hon. Friend Sir William Cash for tabling these new clauses and I commend him on his tireless work in taking forward the interests of his constituents around the terrible events that occurred at Mid Staffordshire NHS Foundation Trust and the subsequent steps he has been involved with all the way through to improve standards of hospital care provided to the people of Stone and the surrounding areas. He is also right to pay tribute to my hon. Friend Jeremy Lefroy, who has worked tirelessly not just on this Bill, but as an advocate for his constituents and local patients. He is a great credit to the people of Stafford and, party politics aside, being a Member of Parliament is about public service, and he embodies the very best of that in the work he has done in bringing forward this Bill and in his advocacy of the needs of his local patients.

My hon. Friend the Member for Stone was also right to say that we need to learn the lessons of the Francis inquiry and translate some of those terrible learned experiences into improvements in care through this Bill. I believe that is exactly what this Bill will help to achieve when, hopefully, it becomes law.

My hon. Friend has tabled two perceptive amendments that seek to extend the principle behind clause 1 of the Bill to other areas of the CQC’s work. While I applaud the sentiment behind these new clauses, I would like to briefly explain why I do not believe they are necessary.

New clause 2 would require the CQC to include safety of care as an indicator against which providers of health and adult social care services are to be rated. It would require the CQC to consider safety in the ratings of quality that it now produces following every inspection of a hospital, social care provider and GP practice. The question in considering this new clause is not whether safety of care should be considered in the CQC’s performance assessments of providers and reported on. Of course, safety is, and should be, a major consideration in how the CQC carries out its work. Rather, the question is: should this House prescribe the way that the independent regulator conducts its business?

There is a key distinction that needs to be made here. Clause 1 relates to the requirements that are placed on providers of health and adult social care services. Importantly, it does not place an additional requirement on the CQC itself. This new clause is different in that it would have the effect of instructing the CQC in how to carry out its regulatory role. The previous Government established the CQC under the Health and Social Care Act 2008 with the primary objective, under section 3, to protect and promote the health, safety and welfare of people who use health and social care services. This is its core purpose, and we strongly believe that the CQC can be an effective regulator only if it is free from undue influence from Ministers.

The Care Act 2014 underlined this by putting in place a number of measures to enhance the CQC’s independence: the appointment of chief inspectors of hospitals, general practice and adult social care as members of a new unitary board and the removal of nine separate powers for the Secretary of State to intervene in the day-to-day operation of the CQC. As part of this, the Secretary of State delegated the function of devising the ratings methodology when putting in place the new arrangements for ratings and performance assessments of providers in the Care Act 2014. Devising the indicators against which providers are to be assessed and rated is, therefore, a matter for the CQC to decide, having consulted with the Secretary of State and other appropriate stakeholders.

The CQC has decided to make safety one of the key indicators for the assessment of provider ratings. As a result, safety is a critical component of the CQC’s new inspection regime. Under the leadership of the three chief inspectors, the CQC has put in place specialist inspection teams that are able to scrutinise the quality and safety of care much more rigorously.

These inspections ask five key questions of the services that are inspected: first, are they safe; secondly, are they effective; thirdly, are they caring; fourthly, are they responsive to people’s needs; and, fifthly, are they well led? That is the core of the inspection regime. These inspections no longer simply consider whether providers are meeting the registration requirements, and have moved us away from a tick-box methodology that was in place, sometimes to the detriment of patients, in the past. The inspections now provide a judgment about the quality of care on a scale running from “outstanding” to “inadequate”, offering providers, commissioners and local people fuller information about the quality of care. To date, the CQC has carried out more than 80 inspections and published 48 ratings of acute trusts alone. The CQC’s tougher, people-centred, expert-led and more rigorous inspections are seeing some outstanding care, and it has already rated many services as “good”. This new approach has also exposed some examples of poor care and variations in care, which I am sure we would all agree are unacceptable, and has made quality transparent in a way that it has never been before.

So I am sympathetic to new clause 2, but my sympathy is in part constrained because I am already confident of the great strides the CQC is making to be an effective regulator of health and social care providers. Safety, of course, is one of the key questions the chief inspectors ask when rating the quality of health and adult social care services, and therefore the CQC is already meeting the aim of the new clause. I hope my hon. Friend the Member for Stone will agree that the CQC has made significant improvements, and that safety is already a major feature of its inspection process and ratings of care providers, and will feel able to withdraw his new clause.

My hon. Friend has also tabled new clause 3, which would require the CQC to include its assessment of the safety of health and adult social care services within its annual state of care report. That report is issued under section 83 of the Health and Social Care Act 2008, which requires the CQC to make a report on the provision of NHS care and adult social services and the carrying out of all the CQC regulated activities during the year. Hon. Members will be aware that under the 2008 Act, which established the CQC, the CQC’s main objective in regulating providers of health and adult social is to protect and promote the health, safety and welfare of people who use health care services. As such, safety and the avoidance of harm are already key elements of any CQC assessment of the provision of care by regulated providers.

I entirely agree that the CQC’s annual report should cover safety issues, and indeed the most recent state of care report, published in October, does exactly that. It is difficult to conceive of circumstances in which the CQC’s annual report would not cover the safety of care provided by the organisations it regulates. A report that did not address this important area of safety could amount to a failure by the CQC to discharge it primary functions as set out in the 2008 Act. In extremis, where that is the case, section 82 of the 2008 Act gives the Secretary of State the power to direct the CQC on how to discharge its functions. However, we must be clear that there is a distinction between the power of the Secretary of State to intervene if the CQC fails to perform the primary functions for which it was created and the need for the day-to-day operational independence of the CQC. As my hon. Friend outlined, this Government have rightly ensured that the day-to-day operation of the CQC is free from political interference, and we now have a genuinely independent inspector of health and care. So although I entirely agree with the spirit of the new clause, which seeks to ensure that the state of care report should cover the safety of care, I believe that the current legislative framework strikes the right balance between providing operational independence for the CQC and having a power for Ministers to intervene, in extremis, if the CQC fails to discharge its primary functions—those for which it was set up. Once again, I pay tribute to my hon. Friend’s work in taking forward the interests of his constituents, following the terrible events at Mid Staffordshire, and I hope I have given him sufficient reassurance to allow him not to press his new clauses to a vote.

Photo of Bill Cash Bill Cash Chair, European Scrutiny Committee, Chair, European Scrutiny Committee, Chair, European Scrutiny Committee 10:30, 9 January 2015

I have listened carefully to the arguments that have been put, including those from the Labour Front Bencher. In the circumstances, I am content not to press my new clauses to a vote. There will be an opportunity for reconsideration as the Bill makes further progress and it is just possible that some people will take another look at them—we will have to see. For now, I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.