With this it will be convenient to discuss amendment
No. 165, in clause 16, page 8, line 31, at end insert—
‘( ) Regulations made under this section may make provision for the prevention and management of malnutrition and may include such provision as the Secretary of State considers appropriate for the purpose of safeguarding individuals (whether receiving health or social care or otherwise) from the risk, or any increased risk, of malnutrition.’.
We now come to the vital subject of nutrition, which remains a huge issue in hospitals and care homes. The latest figures from the annual survey of the British Association for Parenteral and Enteral Nutrition, conducted in September 2007, state that 28 per cent. of people in hospitals and care homes are at risk of malnutrition. That is more than one in four people, which we cannot accept, especially as the figures show big increases with age.
The focus in the last 18 months to two years has been on the need for better nutrition in schools. The Government have taken that point on board and are doing something to address it, but the same focus is needed on nutrition in care homes and hospitals.
My hon. Friend the Member for Sutton and Cheam (Mr. Burstow) introduced a very good ten-minute Bill on nutrition in care homes two years ago and put the case strongly, but since then, as the CSCI figures for 2006-07 show, 23 per cent. of people in care homes that provide nursing and 21 per cent. in other care homes were in places that failed to meet the minimum nutritional standards.
We are not talking about meeting an adequate level of nutrition; the minimum nutrition standard says little about what sort of nutrition people in care homes should have, which is why it is scarcely more than a piece of paper. More than one in five people in care homes today still do not receive the minimum nutrition that the Government laid down, which is a matter of great concern. In October, the Government published the nutrition action plan and although I shall be interested to hear further details about it, things do not appear to be getting much better.
People in hospitals are still at risk of malnutrition, which in Britain today is simply unacceptable. The Age Concern report, “Hungry to be Heard”, published in 2006, said that six in 10 older people in hospital are at risk of becoming malnourished, or of their condition becoming worse. As we know, age and the conditions associated with age are a huge problem, meaning that this group remains very significant, though there are of course other vulnerable people, including the mentally ill and vulnerable children.
There is a huge associated cost, as the Government are well aware. BAPEN estimated in 2005 that it costs the taxpayer £2.6 billion to deal with the malnutrition caused in care homes alone. Surely the Bill is an opportunity to address some of the issues in terms of frameworks, so it makes sense to have nutrition specifically mentioned in the measure, and in terms of amendment No. 165, it makes absolute sense. We have talked about making
“provision in relation to nutritional standards in relation to regulated activities”,
which is important. Amendment No. 165 goes on to talk about
“provision for the prevention and management of malnutrition”.
No doubt the hon. Member for Eddisbury will go into more detail about that. We would be minded to support that proposal, and I would like to know his thoughts on amendment No. 151. The Minister acknowledges that more needs to be done to address the issue of inadequate nutrition and the possibility of malnutrition both in care homes and in hospitals. If this is not the place to do something about it, what is, and when will it happen?
I rise in support of the amendment that has just been moved. As the hon. Gentleman rightly said, amendment No. 165 moves beyond simply making provision; it also looks at nutritional standards and seeks to make
“provision for the prevention and management of malnutrition and may include such provision as the Secretary of State considers appropriate for the purpose of safeguarding individuals (whether receiving health or social care or otherwise) from the risk, or any increased risk, of malnutrition”.
In our combined amendments, we seek to impose action on malnutrition on the CQC. Our amendment is drafted in the same terms as subsection (5) on health care acquired infections. I hope the amendment will commend itself strongly to the Minister on that basis, as there is no greater flattery than to be copied, which is precisely what I have done.
In 2006-07, 139,127 patients were discharged from hospital in a state of malnourishment—an 84 per cent. increase from the 1997-98 total of just 75,431 patients. Those are Government figures. In 2006-07, 130,594 patients were admitted to hospital in a state of malnourishment, an 85 per cent. increase on the 1997-98 total of 70,658. The Government had previously admitted to slightly more than a mere 2,000 patients being discharged from hospital in a state of malnourishment. Last year, the nutritional state of at least 8,500 patients worsened while they were in hospital. In the Minister’s own trust, the Royal Devon and Exeter NHS Foundation Trust, 782 patients were admitted with malnutrition, nutritional anaemia or other nutritional deficiency, and 850 were discharged in such a state. That is where deep concern about malnutrition and nutritional standards arises, because some patients are going home or back to their care setting worse off than when they entered hospital, in terms of malnutrition or associated deficiencies.
It is estimated that MRSA affected about 6,000 people in 2006-07. C. difficile has affected about 56,000 people, according to the Government’s figures in “Clean, safe care: Reducing infections and saving lives”, which was published on 8 January this year. I have given figures on malnutrition in an effort to impress on the Government why the amendment is of the most vital concern. It cannot have escaped the Minister’s notice that the figures that I recently put into the public domain have struck a serious chord not only at a national level, but throughout all the regions and local areas. Many hon. Members have read the figures and taken up such issues with the chief executive of their hospital trust. That is the right action to have taken. We are faced with an absolute scandal.
A study undertaken by the National Patient Safety Agency in the summer of 2007 found that some of the greatest barriers to NHS staff undertaking nutritional screening were the lack of weighing scales—we shall return to that point—and the lack of time and training to allow nursing staff to support nutrition. The Healthcare Commission is meant to inspect whether nutritional needs are being met, but the 34 trusts discharging the highest number of malnourished patients actually met the Healthcare Commission’s quality requirements, so the existing system is clearly not working. I hope that the Minister agrees that a stronger legislative incentive is needed.
As we are dealing with the complementarity of the two amendments, I wish to flag up Age Concern’s “Hungry to be Heard” campaign. We are talking about not only malnutrition, but human rights. This is of the deepest concern to members of the Committee, as has been ably highlighted and articulated by the hon. Member for Luton, North. “The Human Rights of People in Healthcare”, the recent report by the Joint Committee on Human Rights, noted that malnutrition and dehydration in care settings breached articles 2, 3 and 8 of the European convention on human rights. It recommended
“that the forthcoming merged inspectorate for health, social care and mental health adopts a human rights framework”— that is the precise issue that the hon. Member for Luton, North has sought to advance—
“with the intention that the framework informs all of the inspectorate’s work and so makes it more effective in fulfilling its statutory duties”.
Our amendment would make sure that the issue was tackled in care homes as well as by health care providers, given the wide remit of the CQC. I therefore very much hope that the Minister will recognise the power of my argument. He clearly intends the Bill to address health care-acquired infections, but why is he not equally prepared for the Bill to cover malnutrition? Given that the statistics are based entirely on the Government’s figures and show that they must be judged to be failing miserably, surely the amendment would be one of the best and most urgent ways of combating malnutrition by giving it legislative power and effect.
I hope that the Minister will recognise that we drafted the amendment in the spirit of improving the health and safety of patients. We made sure that it contained constructive proposals that would be worthy of his consideration and support.
I support my hon. Friend on one of the most important subject areas of the Bill. Amendment No. 165 and amendment No. 151, which was tabled by the Liberal Democrats, seek to address the problem. The Minister now has the opportunity to put into the Bill the words
“prevention and management of malnutrition”,
which are so important.
I previously raised the subject in the Committee that considered the Bill that became the Mental Capacity Act 2005. I received a full broadside from the Royal College of Nursing for mentioning it, and it sent me literature showing how individual hospitals were dealing with the problem. That is all very good, but we are talking about the situation at the heart of care. Addressing the problem of malnutrition should be mainstreamed throughout every hospital and care home. It is an indictment of our position today that we are even suggesting in 2008 that such a subject needs to be put into a Bill because there is still a problem after many years.
I will not go into the details of my experience, but I have reached an age at which I have had to care for several elderly relatives, including single people with no spouse, my mother, who died four years ago, and my step-father. My personal experience involving one family in hospitals around the home counties was that I felt that I had to organise teams of family members to go in.
The hon. Lady is talking about someone in care who is visited by relatives and friends. There should be much more concern about those who have no one visiting—those who are isolated, and perhaps without mental capacity, who would need some kind of human rights basis to ensure that they were cared for properly.
The hon. Gentleman is absolutely right. When I was visiting my mother in hospital, the lady in the bed opposite was in just such a position. She had a niece who was able to come in once a week. Fortunately, she happened to come in one afternoon just as her aunt had slipped into a diabetic coma. It was really unbelievable that it needed a relative to come in by chance to reverse that.
I want to flag up why management is important. I mentioned in an earlier debate that people in the public sector sometimes start working in silos. That is no criticism of individuals. I worked in the health service—in a hospital—in the 1970s. However, there are real problems, especially on trauma wards to which elderly people are admitted. A lot of the focus is on getting people to theatre and caring for people post-operatively, but there are people on the ward with fractured hips and so on. We should consider the day-to-day management of those people as individuals, rather than just the operation that they have undergone. With elderly people, the question of malnutrition is often not just that they have not eaten sufficient food or sufficiently nutritionally balanced meals. As people get older, their bodies sometimes do not process certain elements as well as they did when they were younger. There are conditions associated with elderly people in hospital, such as certain behaviours and vitamin-specific deficiencies. It is not always the case that the patient has not eaten sufficient foods with a particular vitamin content. Sometimes the body is getting old and not processing that well enough, which is something that can be addressed.
When considering malnutrition, the need for management is important. When one goes on to a ward or into a nursing or residential home, one needs to know who is in charge. When I go on to a hospital ward to visit a relative, I want to know who is in charge because I want to know who is taking responsibility for the overall care of that relative.
Mr. O'Brien rose—
I will give way in a moment. I will not bore the Committee, because I have told the House enough times, but I remember when my step-father was in the last few weeks of his life and in hospital with cancer. He had macular degeneration and his eyesight was very poor. I once went in to see him when they brought the food round and he was having sandwiches. I said to him, “Why are you having sandwiches; what else was there?” Because his eyesight was poor and he knew that he could not cope with a knife and fork and a plate of hot food on his own, he had opted for sandwiches for three days because he felt that he could eat those tidily on his own, without any support. It was very sad. As hon. Members can imagine, I went to find the person who was in charge to have a little word about that.
I thought I would intervene before we got to bit about who is in charge because I was beginning to quake. If this issue is not dealt with in the Bill, current good practice will be lost. Such practice includes serving food in hospitals on red trays to those who are vulnerable to bring the matter to nurses’ attention. Nurses often get it in the neck on this issue, but I do not think that it is at all their fault—often they are not given the chance. They have to deal with data inputting and all sorts of things that take them away from that hand-holding bedside care, which is after all what they want to do.
I am grateful to my hon. Friend. He is quite right to flag up the fact that there is good practice. I must pay tribute to Wokingham hospital, which looked after my mother during the last few weeks of her life. The nutritional care there was a classic example of nursing practice at its very best. She was weighed regularly, and as she became unable to take solids, her diet was changed to mashed food and puree. Not only that, the nurses chatted to her and found out what she needed, and there was somebody in charge. That was very important.
I will conclude by saying to the Minister that yes, there is good practice, but—I return to my first remarks—the issue should not be whether someone is lucky enough to be in a hospital in which there is good practice. Good practice should be the norm everywhere.
I have one final point, in which I have an interest because I am now a pensioner. People are allowed to say, “I can’t believe that.” I notice no one did. This returns us to a point raised by the hon. Member for Luton, North, and Age Concern will bear this out. People are living longer and there are many women who still live longer than men. In the coming decade or 20 years, more and more ladies will be single or widowed with no immediate family to look after them in hospital. The problem is not unique to women, but the demographics show that that is often the situation.
One other point is that as society moves on, people and families become more mobile and no longer live in tightly knit communities. It is sometimes more difficult for people to visit than it might have been in the past.
That is right, and sometimes people are in hospital or care for many years. Things can be difficult for families for all sorts of reasons. For example, they might live abroad. I think that we have talked about the subject in the House for long enough. Something must be done now, and the Bill offers a unique opportunity for us to get that really good practice everywhere. People will otherwise feel afraid—and I mean afraid—to go into hospital. If I were frail, as some of my relatives were, and there was no bossy niece or daughter to come and find out who was in charge, I would be afraid. That is an indictment on the country and the services that are provided. We can do something about that in the Bill.
I think that I made it clear during the evidence-giving session that I share the strong views of members of the Committee on the importance of good food and nutrition in hospitals. Given the amount of time that we have rightly dedicated to discussing the matter, it is fair to put on record what provision there is at the moment. There is often a degree of ignorance about this—not among hon. Members, but out there.
One of the core standards on which the Healthcare Commission monitors, lists and ranks hospitals is food. Core standard 15a states:
“Where food is provided, healthcare organisations have systems in place to ensure that patients are provided with a choice and that it is prepared safely and provides a balanced diet”,
while 15b says:
“Patients’ individual nutritional, personal and clinical dietary requirements are met, including any necessary help with feeding and access to food 24 hours a day.”
For assessment against core standard 15, the Healthcare Commission will use the following criteria, which were signed off by the Secretary of State in 2007-08. Patients should be offered
“a choice of food in line with the requirements of a balanced diet...reflecting the needs and preferences and rights, (including faith and cultural needs), of its server-user population.”
The preparation, distribution, handling and serving of food is carried out in accordance with food safety legislation and national guidance including the Food Safety Act 1990, the Food Safety (General Food Hygiene) Regulations 1995 and EC regulation 852/2004.
Core standard 15b requires patients to have
“access to food and drink 24 hours a day”.
The criterion for assessment is:
“The nutritional, personal and clinical dietary requirements of individual patients are assessed and met, including the right to have religious dietary requirements met”,
and that patients requiring assistance with eating and drinking are provided with appropriate support.
Those are the core standards, and I absolutely accept that, as the hon. Member for Tiverton and Honiton said, performance is not always up to those standards. If hon. Members care to be really nerdish, they can go and look at the Healthcare Commission’s annual health check of all the hospitals in the country, and examine the details. They could compare and list every hospital’s performance in its food provision, and whether it complies with those standards. What we must do, as the hon. Lady rightly said, is to bring everyone’s standards up to those of the best.
The hon. Member for Leeds, North-West, who spoke on behalf of the Liberal Democrats, highlighted the fact that in the autumn, the Under-Secretary of State for Health, my hon. Friend the Member for Bury, South (Mr. Lewis), who leads on social care, launched the national action plan to address the issue of older people and nutrition. That plan followed two nutrition summits in March and July last year, which were attended by leading charities, clinicians, nutrition experts and care home representatives. There was an acknowledgment that good food is important, and that standards have risen. Patient environment action team assessments showed an increase from only 17 per cent. of food being good in 2002 to more than 34 per cent. of food being excellent in 2005-6. The results for 2006-07 showed a continued increase to 44 per cent. being excellent.
The Healthcare Commission’s national in-patient survey shows that 53 per cent. of adults rated the food that they ate in hospital as good or very good. The better hospital food programme was launched in 2001 to introduce five key improvements: 24-hour service, NHS snack boxes, additional snacks twice a day, a hot meal in the evening, and menus including three dishes created by leading chefs. An awful lot is already happening on the ground with food and nutrition, but I accept the points made by hon. Members, and acknowledge that more can be done.
In December, we published our annual operating framework, which recognised for the first time the importance of including regard for the patient experience as one of the NHS’s five main priorities. If there is one thing that comes up time and again in consultation with the public on their experience as patients, apart from the question of how they are treated by staff and receptionists, it is the quality of food and the way in which it is delivered. I hope that by including that important issue in the five main priorities that the Government have given the health service, we will continue to see further improvements.
My hon. Friend the Member for Eddisbury referred to best practice, and the Minister’s focus is the nutritional value of the food that people are given to eat. The issue should not be about best practice; it should be about standard practice. We have talked about dignity and human rights, but the issue is about people who cannot get food to their mouths, and leave hospital malnourished. It is outstandingly awful and a poor reflection on management that more is not being done. Nurses cannot always be blamed, because it is question of the time available to them to meet patients’ needs.
That is exactly why it is important to draw the Committee’s attention—and I am sorry to have detained Committee members by speaking at such length—to those core standards. They are already in place and include any necessary help with feeding. The hon. Lady is absolutely right: the issue is not just about the quality of food, and whether it is organic or locally produced, although such improvements are a good thing. During a visit to west Cornwall, I witnessed a fantastic initiative to replace almost all food—up to 85 per cent.—of the food served in Cornish hospitals with local produce. That has increased the quality of meals and patient satisfaction and reduced costs, and the reduced number of food miles has reduced the impact on the environment. Good things are happening, but the hon. Lady is absolutely right that the issue is not just about food.
As the hon. Member for Tiverton and Honiton said, a patient could be receiving the diet they need, but a problem such a failure to process vitamins might need additional attention. That is exactly why we added the new requirements to the core standards. To return to the impact of the amendments, as I have said before, we are about to put the requirements subject to registration under the Bill out to consultation. I encourage hon. Members and outside bodies who have argued strongly that nutrition, food, and the way in which they are delivered, should be included in the core requirements, to continue to do so, as they will be pushing at an open door. However, we should be careful to strike a balance, as we do not want to tie the hands of a new independent regulator in advance of setting it up. However, its representatives attended the evidence session at which the subject was discussed at some length last week, and I hope that they will read the report of this Committee sitting and take note of the points that hon. Members’ have made.
From the conversations that I have had with Anna Walker, I know that she feels extremely strongly about the matter. I think that I am right in saying that the Healthcare Commission highlighted food as an important issue in its press release and commentary on last year’s annual health check. The issues have therefore been taken on board, and I hope that the new regulator will do so, too. I have provided the Committee with examples of the way in which key delegated powers will be used, not just because I feel strongly about the topic but because we discussed it at length in our evidence-taking sessions. They include a possible registration requirement in
“making sure people get the nourishment they need.”
The examples are not final versions, and it will be necessary to consult on them. They illustrate how registration would work in practice and demonstrate the importance that I personally attach to the issue of food. I think that the example helps to demonstrate that the Bill is sufficiently wide as it stands to allow regulations of the kind that have been requested to be made if required. On that basis, I ask the hon. Gentleman to withdraw the amendment.
That was a lengthy but useful and at times passionate discussion of an important issue. Some notable points were made, such as the hon. Member for Eddisbury’s observation that although the number of people affected by health care-acquired infections is an enormously important subject, that figure is far lower than the number of people affected by malnutrition. That shows how important the issue is. The hon. Member for Tiverton and Honiton’s account of her personal and professional experience—I am not implying anything about her age or stage of life, but merely referring to the experience that she shared with the Committee—added greatly to the debate. I am glad that the human rights side of the debate was brought out, as the issue is central to the human rights thread that I discussed on the first day of our clause-by-clause consideration of the Bill. Some of us believe that that thread should run more obviously through the Bill than it does.
I accept what the Minister said about the existing provisions and the Healthcare Commission’s core standard 15. I do not think that anyone is suggesting that the amendments would resolve the problem of insufficient nutritional standards and malnutrition in health care and care homes. However, I still believe that they are essential if we are to make such provision part of the new regulatory framework. I am slightly concerned about the fact that the Minister hoped that the regulatory framework would take the matter on board. It must do so, and the framework should be set out to ensure that it does so.
I acknowledge, too, the fact that the Minister has given us a little more information about the national action plan. The challenge for Government, which the Minister accepts, is to come up with a range of measures to address the situation. We see whether that is the right plan and whether it works. I do not believe that what the Minister said changes the need for good nutrition, as well as the need to avoid malnutrition, to be built into the new regulatory framework. That is important, because nutrition is fundamental to the effectiveness of health and social care. Poor nutrition undermines health, it costs the taxpayer an awful lot of money, and it has an effect on patients, service users and their families. I would have welcomed the Minister saying that he would consider and discuss the matter further.
The hon. Gentleman implies that I hoped that nutrition would be part of the regulatory framework. I expect that it will, but it is not for me to pre-empt a decision by the House. We will consult on the regulatory framework, and I doubt that we shall retreat from the importance that is laid on nutrition in the current framework. However, that is a decision for the House to make following the consultation—it is not one for me to make in Committee.
I can see where the hon. Gentleman is going. He has the support of my party and myself, and I endorse what he is saying. I accept that the Minister is sincere and thorough in what he seeks to achieve, but I have already flagged up to the Chairman of the Committee my hope that the question on amendment No. 165, which I tabled with my hon. Friends, is put separately, and I hope that the Minister might suddenly decide to accept it.
Importantly, the Minister has not moved from his reliance on consultation. We must therefore ask which is the cart and which is the horse: we have an obligation to suggest that malnutrition is of the greatest importance, alongside the other factors mentioned in clause 16(3). We must remember that the Healthcare Commission states that 34 of the most malnourished trust areas meet the current care standards. The system is clearly not working, and new legislation is patently necessary.
I thank the hon. Gentleman for clarifying his position and making his case. I fully accept the Minister’s sincere commitment to dealing with the problem, but as he has not indicated that there will be further consideration of the question of whether nutrition should be mentioned in the Bill, alas, we are in a fundamental disagreement. We, along with the official Opposition, believe that the matter is too important, and too central to the essential purpose of the Bill, to accept what the Minister says.
The amendment can be dispatched pretty quickly. It would add a new paragraph to subsection (3), making the reduction of health inequalities part of the Care Quality Commission’s remit, and ensuring that the commission would have to give due regard to the Disability Discrimination Act 1995. I am relatively confident that our approach on both those issues will find favour with Members on both sides of the Committee.
Under a previous amendment, I put on the record the latest Government figures on health inequalities and discussed inequality gaps in circulatory disease mortality, infant mortality and life expectancy. Those figures were obtained from Government publications. Rather than take up the Committee’s time going through those figures again, I pray them in aid of this amendment.
“The registration requirements explicitly say that they cannot bite on public health issues, only on health care issues.”——[Official Report, Health and Social Care Public Bill Committee, 8 January 2008; c. 12, Q13.]
That is also relevant to clause 19.
I must make an additional point about the amendment. It seems sensible that the commission should have regard to the Disability Discrimination Act in relation to its inspection of health care premises and in any inspection it makes of health care assessments. That is also related to a previous point. I hope that the Minister will take those points on board.
Colleagues and Members on both sides of the House will have received a report from Mencap on this issue in recent months. The report is particularly relevant to people with learning disabilities who are admitted to hospital wards. Clearly, the 1995 Act is not being enforced in those circumstances. The inspection process needs to be strengthened.
I shall maintain strict confidentiality, but I have a constituent in his 40s who is seriously affected by Asperger’s syndrome. Recently, he has repeatedly been admitted to the general ward in the local hospital, which has been something of a challenge for him, for the staff at the hospital and for his increasingly elderly parents. Having the rights and opportunities that would give him protection equal to that of others who might avail themselves of those services has proved extraordinarily challenging. My hon. Friend makes an absolutely valid and cogent point.
Perhaps with those two examples, the Minister will think that it is in the Government’s interests to ensure that there is no such difficulty. I hope that rather than rely on the more generic definitional and scope phraseology that is characteristic of the Bill, he will find it appropriate to consider health inequalities, which is clearly a difficult area, with a particular focus on the Disability Discrimination Act.
In the interests of brevity, I shall make only a few comments. I wish to put on record again the need for the Bill to address the hugely important issue of the health inequalities that result from disability, particularly certain forms of disability. People who have learning difficulties or mental health conditions are far more likely to contract a range of conditions, but such people are unlikely to receive health checks.
The Minister is aware of the issue and I know that he wants to tackle it. The amendment would be useful because regulatory arrangements should encompass the need to reduce health inequalities, as he would acknowledge. It is an important issue and it would be sensible to put the measure in the Bill. I look forward to what he has to say on whether the matter can be addressed in the Bill or in other ways.
It is pleasing to hear that reducing health inequalities and discrimination based on disability is a priority that is shared by all hon. Members on both side of the Committee. The Government were recently criticised for granting more time to the independent body that sets the allocation formula for primary care trusts because it wanted more time specifically to look at what more could be done to reduce health inequalities. That did not go down well in all quarters, but it illustrates that the Government’s overriding priority is the reduction of some of the glaring health inequalities.
The amendment would include specific references to those two issues within the scope of the registration requirements. As I have said repeatedly this afternoon, those requirements will soon be subject to public consultation. I encourage those who are interested in the matter to respond to the consultation. However, we do not believe that we need to specify those matters in the Bill. Let me give one example. It may not be within the power or ability of a specific provider, depending on the nature of the provider, to reduce health inequalities. However, if, following the consultation, registration requirements on health inequalities and the reduction of disability on the basis of discrimination were identified as practical and appropriate, the clause as drafted will enable us to cover that in regulations.
As I have already mentioned, the new Care Quality Commission may also take action when providers do not meet the requirements of any other legislation that it considers relevant. That is in the Bill. Hence, if there are elements or requirements under the Disability Discrimination Act 1995 that the commission thinks are relevant and are being breached, they can be included for registration purposes. The commission will have the power to act if providers do not meet the requirements.
I understand and sympathise with the motivations behind the amendment, but the Government consider it unnecessary, because the Bill will enable regulations to be made when appropriate, and for intervention to be made when the 1995 Act is breached. I therefore ask the hon. Member for Eddisbury to withdraw the amendment.
In the light of what the Minister said, it would be disproportionate to press the amendment to a Division. The matter might, however, be tabled for consideration on Report, and I dare say that it will be a key point in another place if the Minister chooses not to reflect our helpful discussion. I beg to ask leave to withdraw the amendment.
I shall be brief. I concede from the start that this is a probing amendment and I shall not press it to a Division. It is important, however, to give some kind of guidance to the new commission—the new regulator—and ideally the Bill would include the codes of practice established by the General Social Care Council.
The council was recently established by a measure enacted by the Labour Government, so it is not out of date. I hope that the measure would involve a simple carry-over and that my hon. Friend the Minister will ensure that it happens, whether by inclusion on the face of the Bill or as a code of practice issued by the Commission.
I too shall be brief. I recognise that the amendment is probing. It is helpful to the Committee that the hon. Gentleman has sought to ensure that concerns encompassed by the amendments are put on the record. The experience from the registration of social workers and student social workers is that, without clear compulsion, registration will happen slowly and inconsistently throughout the sector. In the consultation on the arrangements for the registration of domiciliary care workers, there was general agreement that compulsion should be in place to ensure that registration takes place in a timely fashion and to ensure a level playing field in the delivery of social care services.
Having said that, there is a further debate to be had about the registration of the social care work force, most immediately about domiciliary care workers, but also, as I flagged in relation to clause 5, about any Government plans to regulate informal carers. That must be seen as a complementary issue, riding parallel to the one raised in the amendments. It is important that the matter is debated properly before an amendment such as No. 232 is included in the Bill. The hon. Gentleman is therefore right in his judgment that the amendments should be considered probing, but they reflect important considerations, which I hope the Minister will consider.
I rise to speak briefly to amendment No. 232, which I tabled. First, let me say that we fully support amendment No. 231, which was tabled by the hon. Member for Luton, North. To some extent, it is a tidying-up exercise and gives some of the clarity that the Bill lacks about the codes of practice for social care.
Amendment No. 232 is a probing amendment, but a beautifully simple one. It would impose specific requirements on the registration of the social care work force. The reason for tabling it is that this is an important issue. As the Minister will acknowledge, the GSCC makes it absolutely clear that it believes that social care providers registered with the new CQC should employ only workers who are registered with it. We agree with that and I would be interested to know the Minister’s views on it.
As the hon. Member for Eddisbury has said, without the necessary powers and the monitoring of employer compliance, that requirement is probably not worth the paper that it is written on. We must make this measure work to ensure that people have confidence that all social care workers, including students, who treat service users are properly registered. I am sure that the Minister will agree with that. Is this not, therefore, an opportunity to push towards that position?
Clause 16 is about allowing regulations to be made that set the requirements that providers and managers of regulated activities must comply with in order to provide or manage services. Those will include crucial requirements that are needed to ensure that services are of an appropriate quality and to secure the health, safety and welfare of patients and service users.
Amendment No 231 would make express provision for regulations to impose requirements on providers of regulated activities to comply with the GSCC codes of practice. The GSCC has issued these codes for social care workers and social care employers, as required under section 62 of the Care Standards Act 2000. They provide a clear guide for those who work in social care settings about the standards of conduct that workers and their employers should meet. The GSCC expects those registered with the CSCI to comply with the codes of practice.
The CSCI currently uses the codes of practice when inspecting care providers against the national minimum standards. I agree with my hon. Friend the Member for Luton, North that the system has worked well. In future, the commission itself will set the criteria by which compliance is assessed, and although we will be consulting on the registration requirements shortly, as I have repeatedly said, we would expect the new commission to continue to use the codes of practice in its assessment of compliance with requirements in future. I therefore see no reason for changing these arrangements when the new commission is established.
Amendment No. 232 would make express provision for regulation to make requirements as to the registration of the social care work force. The Care Quality Commission will not be responsible for the registration of social care workers; that role is carried out by the social care work force regulators, such as the General Social Care Council. Such a provision would duplicate legislation under section 55 of the Care Standards Act 2000, which gives regulatory powers to extend registration of the social care work force. It is illogical to have these powers resting with two bodies.
As we discussed earlier, the commission will register managers of certain services where they have significant amounts of autonomy and where there is little supervision. We would, of course, expect all providers to employ appropriate staff to deliver the activities that they are registered to provide. That is essential to ensure that the services are safe and of acceptable quality. Clause 16 already states that regulations may
“make provision as to the persons who are fit to carry on or manage a regulated activity” and
“the manner in which a regulated activity is carried on”.
That will enable requirements to be made about the appropriateness of social care workers. The amendment is therefore unnecessary.
We will be consulting shortly and I urge those with an interest to participate in this consultation. In the light of that, I ask my hon. Friend the Member for Luton, North to withdraw his amendment.
With this it will be convenient to discuss the following amendments: No. 14, in clause 16, page 8, line 22, leave out from ‘means’ to end of line 31 and insert
‘such infections as the Secretary of State shall by regulation define’.
No. 15, in clause 16, page 8, line 39, at end add—
‘(10) In respect of such cases as the Commission has taken action on the prevention and control of health care associated infections, within the regulations established under subsection (5), the Secretary of State shall be required to make a written statement to Parliament,’.
No. 25, in clause 25, page 13, line 33, at end insert—
‘(5A) The Commission shall notify Parliament of any notices served due to breaches in regulations made under section 16(5).
We arrive at the discussion on health care associated and health care acquired infections. Of course, amendment No. 25 would add new subsection (5A) to clause 25. The amendments are intended to do no more than finesse the Government’s approach to health care acquired infections and to make the Government more accountable to Parliament, through the CQC, for their performance.
There is a debate to be had about why the Government saw fit to include explicitly in the Bill health care acquired infections but not, for example, malnutrition, as we have said. MRSA affected about 6,000 people in the last financial year and, according to the Government’s own figures, clostridium difficile affected 56,000 people, as was cited in an earlier discussion. The Committee’s fear will be that the clause is less about benefiting patients and more about politics, both in general and specifically.
I would argue that the clause is about keeping the Prime Minister’s back as he blunders through health policy. For example, on Sunday 6 January, the Prime Minister promised, on “The Andrew Marr Show”:
“If you go to hospital you will get screened by next year for MRSA or C. difficile.”
That was later reported by the BBC under the headline,
“Brown pledges superbug screening: All patients entering NHS hospitals in England will be screened for MRSA and clostridium difficile.”
No one from the Government sought to correct that story. However, two days later, on 8 January, the Health Secretary’s infection control strategy, “Clean, safe care: Reducing infections and saving lives”, reported on clostridium difficile:
“Screening for colonised patients is inappropriate (most potential cases would not be identified, and it requires a stool sample), and colonisation without symptoms is not considered to increase risk of transmission.”
The Government have failed for years to isolate infected patients, which the evidence says would work. Professor Pat Troop, chief executive of the Health Protection Agency, said in 2004:
“The most effective way of controlling the spread of both Staphylococcus aureus and MRSA in hospitals is through early detection and appropriate isolation and treatment.”
The Government’s own best practice guidance from the Department of Health states that the
“current scientific thinking recognises the evidence of many years’ experience that the isolation of patients with suspected or proven infection is effective in reducing transmission” of hospital infections. The Department notes that
“Some countries have been particularly successful in controlling MRSA. Notable is the experience of the Netherlands. The Dutch strategy has been based on a policy of ‘search and destroy’. This involves screening patients for MRS A and isolating those found to be positive (colonised or infected)”.
It is vital that we recognise that series of reheated promises. With this group of amendments, the Committee has an opportunity to reinforce through legislation the message that the Government must get this right.
Does my hon. Friend agree that nurses are terribly constrained? Nurses tend to be on the front line and they get it in the neck when things go wrong, so unless we give them the resources they need to combat infection, such as the opportunity to isolate patients, we will not make real progress.
I am very grateful to my hon. Friend. Her experience and practice in the profession gives her a particular authority. She reinforces a clarion call from nurses to be allowed to do what they know to be the right thing in order to give the best care and protection to patients.
There has been a series of reheated promises from 2003 to the present day, including promises on the appropriate provision of single rooms and isolation facilities for infected patients. The I gave all come from press releases from the Department itself over the past five years, yet there has been a significant failure to deliver. In the Bill, the Committee has an obligation not to duck the issue, not to try to pretend that it is not happening, not to be too sympathetic to the Government and not to fail to embarrass the Government. The Government happen to have been the people on watch during this failure, so they must take it in the neck, and it is right that we hold their feet to the fire. The amendments are an opportunity to do just that.
Back in 1998, during the Labour party’s first year in power, isolation rooms were turned into offices, and by 2003 there were very few trusts with proper isolation facilities. I shall not take up the Committee’s time by reeling off the statistics, but I would not put this argument to the Committee unless it was well supported. In 2005, there had been little progress on isolation facilities; in 2007, three quarters of trusts still lacked isolation facilities; and as we reach 2008, fewer than 50 hospitals have had a deep clean. On top of that, money has been taken from local NHS trusts to pay for it.
In the light of that failure, there is a strong argument for the CQC to report regularly to Parliament on the Government’s performance, as amendment No. 16 proposes. I hope that the Government do not lack the confidence to accept that proposal and that they will regard the amendment as a part of the frank accountability that is expected both by people whom they wish to see in receipt of great health care, and by all of us, so that we can be confident that the Government tackle the problem in the right way.
While debating this group of amendments, I should alert the Committee to the fact that there is no new money backing up the Government’s proposals. I am sure the Committee well knows the following arguments, but the Department of Health originally said that deep cleaning could cost as much as £50 million, and then admitted that the figure was only an indicative amount. The Department also admitted that strategic health authorities will be expected to manage the funding of the programme from within their own regional financial plans. Now, the Government have gone even further and confessed that the money will be found not even by SHAs; instead, local NHS trusts will foot the bill.
On the first deep clean at the Maidstone and Tunbridge Wells NHS trust, which is clearly of great topical import, the Department said:
“The funding for deep cleaning at Maidstone and Tunbridge Wells NHS Trust is coming from primary care trust lodgements held at the South East Coast SHA for strategic purposes.”—[Official Report, 5 December 2007; Vol. 468, c. 1316W.]
So we have that from the Government themselves. Amendment No. 16 seeks to ensure that there is genuine commitment to back up the Government’s rhetoric.
Amendment No. 14 is a probing amendment that arises from a concern about the Bill as drafted. Why has the Minister opted for the measure as drafted, rather than a statement of names, for example MRSA or C. diff? Is it sufficiently narrow to exclude non-health care associated infections, but sufficiently broad to capture health care associated infections? There is a further political concern, given the Secretary of State’s statutory influence over the commission, that as new “super-bugs” arrive—as sure as eggs are eggs, they will—the Secretary of State will try to prevent them from being treated as health care associated infections by the commission, in order to massage the Government figures. The Committee is surely under an obligation not to let the Government have licence to do that. The health and safety of patients is too important to allow that risk to leave this room. Obviously if the matter is left to regulations, the Secretary of State still has the power to do nothing about it—it is power that matters—but at least if amendment No. 14 is accepted, he loses any clandestine power he might have.
Amendment No. 15 arises out of the incidents at Maidstone and Tunbridge Wells. Although it would not protect against the delays that happened there, as there were delays in the publication of the Healthcare Commission report on compliance with the hygiene code, it would give right hon. and hon. Members an alert as to when action is taken by the commission, and as such would lead to freer and, hopefully, franker debate in Parliament. Amendment No. 25 seeks to generate a similar report as regards notices served on service providers.
The Minister needs to answer a number of questions in this area. He must also grab the opportunity provided by the amendments to accept our earnest intent to give effect, through those who are best qualified to help it happen, to efforts to tackle one of the most appalling concerns that people have about our health service. They fear that when going into a health care setting, they risk coming out either with a hospital acquired information or, worse still, not coming out at all because they will succumb to it.
We must find a way to support the Government in achieving our aims. We cannot wait for another Government. We have to get on with it. The amendments give us that opportunity. I genuinely hope that the Minister will not think that I am just taking an opportunity to have a good old bash at him and his team. Far from it. This problem is of such importance—we see this all across our constituencies. Like other hon. Members, I have a number of constituents who have either lost loved ones through hospital acquired infections or who continue to suffer from very serious conditions that they acquired when they should have been being treated. I hope that the Minister will take very seriously what we propose in the amendments, which are central to the integrity of the Bill. Unless the Minister can satisfy us on this, we will press them to a vote.
I apologise for taking up the Committee’s time, but I want to make some brief comments. As the Minister would probably accept, the Bill is being touted, not by the Government but elsewhere, as one that will first and foremost tackle health care acquired infections. That is one of the problems of having so many different and varied parts to a Bill, which is often inevitable. In many ways the public see this as the number one issue in the Bill.
To echo the hon. Member for Eddisbury, just before Christmas I called on a constituent who had various health care problems. She told me that she was not prepared to travel from Otley into Leeds for an operation because she did not want to catch MRSA. Of course, perception and reality are not always the same, but the perception and fear is an issue in itself, in addition to tackling the reality of health care acquired infections, which the Minister has made it clear he is very keen to do.
The Bill sets out to deal with health care acquired infections, and we are considering a framework for how we can do that together—I echo the comment that we have to work together and we will support the most appropriate measures. We are trying to put in place the strongest, the best and the most appropriate framework for enabling people to deal with such infections. I believe that the amendments are helpful. Surely it makes sense to have some statutory reporting procedure as part of the framework for dealing with health care acquired infections, and of course it makes sense to have parliamentary accountability as part of that.
I am deeply grateful for the hon. Gentleman’s support. To make it absolutely clear, one would want to press amendments Nos. 16, 15 and 25. I made it clear that amendment No. 14 was a probing amendment. The hon. Gentleman is offering his support. I wanted to make it clear precisely what I hope we will have an opportunity to vote on.
I thank the hon. Gentleman for his clarification. I simply wish to ask the Minister a question. As part of the framework that we all want to see, are some of these suggestions—not amendment No. 14 but the other amendments—useful? If not, what will be there in their place? If they will not be in the Bill, how will they be brought in to ensure that we have the best and strongest framework possible for dealing with this very real problem that we all want to be dealt with as strongly as possible?
In spite of the invitation from the hon. Member for Eddisbury, I have to say that I suspect that the amendments are more about the Opposition’s desire to have a run-around on health care-associated infections, rather than to address the substance of the amendments and their impact on policy. The reason for that is perhaps that, as the hon. Gentleman is well aware, both MRSA and C. difficile rates are falling steadily, which is very welcome. I think that, as a consequence of that, the amendments have been grabbed out of thin air to give the Opposition an excuse to discuss the issue.
The amendments are flawed. Amendment No. 15 would require the commission to report to Parliament every time that it took any action related to any requirement in the regulations connected with the prevention and control of health care-associated infections. Amendment No. 25 would place a similar requirement on the commission, but is limited to the issuing of warning notices rather than any action. Amendment No. 16 would require the commission to make an annual report to Parliament specifically on the action that it had taken regarding regulations under clause 16 relating to health care-associated infections.
I understand and sympathise with the Opposition’s desire to ensure that Parliament is kept fully abreast of action that the commission is taking, but I question whether the proposed approach is proportionate. Of course it will be important that the public have a full picture of how the services in their area are performing. They do already, through a number of measures. I have already described the annual health check. When the CQC goes in on an issue of health care-associated infections, given the new enforcement powers that the Bill gives it—the ability to intervene earlier—it will be entirely free to publicise its activities at any time when it is taking action. However, it is up to the commission to make a judgment as to whether and how much it wants to publicise every single action that it takes in a particular area. That is why we have made provision in clause 83 for regulations to set out when the commission must publish details of the enforcement action that it has taken.
That flexibility is very important. It is up to the commission to decide on the most proportionate response. For example, we expect the commission to be on top of any breach of registration requirements and to respond appropriately. In the majority of cases, that will probably mean a low-level response to nip the problem in the bud—for example, by specifying the issue of concern and alerting the person to what needs to be done to prevent the matter from escalating. I do not imagine that Parliament would consider it a good use of its time for reports to be laid every time that the commission takes action of that type.
On amendment No. 25, warning notices are intended to be used for first-time or minor offences. The issuing of a notice should encourage a provider to change their behaviour to comply with the requirements. If the failure is remedied within the set timetable or has already been put right when the notice was issued, no further action may be deemed necessary in respect of the specific incident. If, however, such matters were referred to Parliament, the issuing of a warning notice would not represent a low-level intervention, in that the provider concerned would be named to Parliament. In those circumstances in which this requirement would apply, it would rather undermine the intended purpose of a warning notice. While I understand the Opposition’s concern about parliamentary accountability, I believe that the reporting requirements in the Bill are perfectly adequate and that the proposed amendments would place considerable and unacceptable extra burdens on parliamentary time.
Under clause 77, the commission is obliged to report annually to Parliament on a range of matters, including the provision of NHS care during the year. That is the same as the current position with regard to the Health Commission and CSCI. I know that Parliament finds such reports both informative and useful. If the Secretary of State decides that there are particular matters on which more detail is needed, subsection (5) of that clause allows them to specify other reports and information that the commission must provide. We would expect that annual report to cover health care-associated infections. We see no need to require the commission to submit this section of the report separately, as amendment No. 16 would require us to do.
Turning to amendment No. 14, the definition of health care-associated infections used in the Bill is the same as that used in the Health Act 2006, in which we legislated to establish the code of practice on infection control. It also included the same exemption that we have used here to exclude circumstances in which the individual is deliberately exposed to an infection as part of the provision of health care. Admittedly, that is not as common a practice as it once was, but there are still vaccines and inoculations that work on the principle of deliberate exposure. For example, I understand that patients were sometimes deliberately exposed to a virus to raise their temperature as part of their therapy. Amendment No. 14 requires us to set out the kinds of infections that should be exempt in regulations. I am opposed to that amendment because the current wording makes it clear that only those infections to which a person is exposed deliberately as part of their health care are exempt. The proposed amendment does not include such a safeguard. That means that potentially any kind of infection could be exempt. More importantly, listing particular exemptions and regulations would make this clause much more cumbersome in its operation.
We are aware of how viruses such as flu are constantly evolving and mutating. We have seen the potential threat from new viruses such as severe acute respiratory syndrome. In the event that a new health care treatment is developed that involves the deliberate exposure of patients to infection, this clause, as amended, would prevent us from using it until the revised regulations had been made. On that basis, I urge the hon. Gentleman to withdraw that and the other three amendments.
I have listened carefully to the Minister, and he reasonably thinks that this is a desperately important area. I am grateful for the support from the hon. Member for Leeds, North-West. Given the way that the amendments are grouped, I want to flag up that although I am happy to withdraw amendment No. 14, which I declared at the outset was a probing amendment, I would wish to make any further consideration of amendments Nos. 15 and 25 dependent on the outcome of pressing amendment No. 16 to a vote.
Amendment proposed: No. 165, in clause 16, page 8, line 31, at end insert—
‘( ) Regulations made under this section may make provision for the prevention and management of malnutrition and may include such provision as the Secretary of State considers appropriate for the purpose of safeguarding individuals (whether receiving health or social care or otherwise) from the risk, or any increased risk, of malnutrition.’.—[Mr. Stephen O'Brien.]
In the light of amendment No. 16, Mr. Hood, you rightly noticed that I did not want to take further action on the other probing amendments in that group, which were not withdrawn.
This is the final group of amendments in this clause. The Bill as drafted requires the Secretary of State to consult before making regulations under clause 16. Hon. Members will be familiar with the various issues that have to be consulted on, which are listed in subsection (3).
Clause 18 requires the Secretary of State to consult on a draft code of practice relating to health care-associated infections before publication. However, in respect of both cases, subsection (6) states:
“Consultation undertaken by the Secretary of State before the commencement of this section is as effective for the purposes of this section” and must be taken into account in any consultation undertaken after that time. The amendments probe why the Government have drafted the Bill in those terms and seek assurance that proper consultation will be undertaken where necessary. Clause 16 specifies a number of areas in which regulations might be made and clause 18 deals with the code of practice.
There is a code of practice that was last updated on 11 January, and the Bill as drafted provides that the Secretary of State need not consult where consultation has already happened; it is a matter for his judgment. As my record in the House will show, I do not want to double up any form of bureaucracy, but it is important that the clause should not allow the Secretary of State to avoid the necessary consultation.
I turn the Committee’s attention to clause 16(3)(k), which relates to complaints. I would have discussed amendment No. 83 in that respect, but it would not be in order for me to do so as it was not selected. However, I hope that the concerns I have outlined show that the subsection as drafted could preclude further important consultation on the regulations. We will have a longer debate on complaints later in the Bill, as the subject will have to be discussed. We must also take into account what we believe is a track record that leaves something to be desired by a Government who have often sought to avoid consultation on key matters. I have alluded already to my experience with community health councils and the NHS 10-year plan some time ago.
There are several questions for the Minister on this first group of amendments. First, can he tell the Committee why the clauses are drafted in this way and, in particular, which previous or current consultations he is referring to? Secondly, will he support a strong local complaints procedure in both health and social care bodies? Thirdly, how will he ensure that the CQC can monitor such complaints in case of necessary interventions?
Let us not be in any doubt about how important it is to have confidence in a complaints procedure, which, at the moment, the Bill is remarkably short in supplying. On that basis, I hope that the Minister will be persuaded by the merit of our arguments in support of these amendments and that, however much they may be probing amendments, they will give him pause for thought.
The problem that we have with these amendments is that subsection (9) makes it clear that the Secretary of State can carry out consultations related to the code of practice prior to the clause coming into force. The impact of this amendment would be to nullify that. However, in order to deliver the new registration scheme to the timetable, which we have all been discussing this afternoon and during previous sittings, we need to have regulations and the code of practice in place by April 2009. That means that we need to begin the consultation on the draft regulations before commencement of this clause. Therefore, subsection (9) allows that consultation to be carried out before the clause has been commenced.
I can understand why some people may think it hasty for the Government to consult on draft regulations before the clauses in the Bill have been commenced. However, we believe that it is important that, if Parliament sees fit to approve this Bill, the new commission should be able to make use of the stronger powers that the Bill is giving it, particularly in relation to the issue that the hon. Gentleman said he was concerned about—tackling health care-associated infections at the earliest opportunity. To hold the new commission back from doing that until commencement would constitute unnecessary delay.
In practice, the proposed amendment would mean a delay, because we would have to wait until after commencement before further consultation would be possible, and any consultation undertaken before commencement would inform the subsequent consultation but would not be valid on its own. We want the new powerful and independent regulator to be able to build on the work of the existing regulators and to do so as quickly and as seamlessly as possible, particularly in relation to the issues of safety, quality and health care-acquired infections. I believe that that is particularly important, given that those are priorities stated not just by the Government but by the public and by Opposition parties, and we would not want this crucial work to be delayed by further consultations, particularly given that there will already have been a wide-ranging consultation on the regulations and the code of practice under this Bill. That is why I ask the hon. Gentleman to withdraw his amendment.
I said earlier that I regard these amendments as probing ones, and I think that this has been a useful exposition. As I also said earlier, I hope that the amendments have provided food for thought, that the Minister will not regard this issue as done and dusted, and that he will reflect upon it as he considers what he might want to bring back on Report. That said, I beg to ask leave to withdraw the amendment.