§ 3.2 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath)
My Lords, I beg to move that this Bill be now read a second time. The Bill has at its heart two key aims—first, to protect vulnerable people from abuse and neglect, and, secondly, to promote the highest standards of quality in the care that people receive, whoever is providing it.
I am glad that so many noble Lords with experience and expertise in this area will speak during our Second Reading debate. I extend a particular welcome to my noble friend Lord Mackenzie of Culkein who will make his maiden speech. He was an excellent general secretary of COHSE and founder of my union, UNISON. He will bring many insights to your Lordships' House, particularly in this area.
The coverage of the Bill is broad. It deals with private and voluntary healthcare, including the most acute and high-tech services provided in that sector. It deals with long-term nursing and social care for older people and disabled people and it deals with a wide range of services for children from residential care through to childminding and day care. In every one of those vitally important services people have a right to expect protection from harm and a right to expect that the care they receive will be of a decent standard.
In many cases that is what they get. However, as noble Lords know only too well, too often that is not the case. A great number of inquiries and reports have highlighted the failings of the current systems for safeguarding people's welfare. The Care Standards Bill provides for radical and far-reaching improvements to the arrangements for ensuring 12 quality and protection in these services. First of all, the Bill provides for the establishment of the national care standards commission. The commission will be responsible for the regulation of private and voluntary hospitals and clinics, of care homes for elderly or disabled people, of agencies providing care to people at home, and of children's homes, residential family centres, fostering agencies and adoption agencies. It will also carry out welfare inspections of boarding schools and colleges which accommodate children.
The Registered Homes Act of 1984 has for many years been considered ineffective and inappropriate in the way it deals with private healthcare services. This Bill will for the first time set out a clear and separate category of independent hospital, with specific regulations made to set out the detailed requirements and standards that every such hospital must meet. In recognition of the importance and distinctive needs of healthcare there will also be a separate division within the national care standards commission which will concentrate on this area.
One of the problems of the current system is that with 100 health authorities in England and another five in Wales the average health authority inspection unit simply does not have the expertise necessary to regulate the acute healthcare services. With the concentration of expertise that comes from a single national body, that will no longer be the case. For the first time we shall have proper, strong standards for private and voluntary healthcare services, with inspection and, where necessary, enforcement action carried out by expert inspectors dedicated to that field. People who use private healthcare can be assured that private hospitals will be required to work to proper modern standards of healthcare with adequate numbers of appropriately qualified staff, equipment and facilities that are up to standard and thorough arrangements for back-up should an emergency arise.
I shall cover briefly the range of services that the national care standards commission will also be responsible for regulating. The commission will regulate the 30,000 care homes in this country accommodating nearly half a million people, including for the first time care homes run by local authorities which until now have been exempt. In providing for a national, independent regulation system, as promised in our election manifesto, we shall remove the inconsistency and inefficiencies of the current regime. The split between local authorities which regulate residential homes, and health authorities which regulate nursing homes, will be replaced by a single and flexible system that will allow care homes to provide a mix of personal care and nursing care appropriate to the needs of those receiving the care. The commission will still require that where nursing care is provided there are appropriate qualified nursing staff to deliver that care. But the regulation system will be geared to people's individual needs and not to artificial boundaries.
For the first time care provided to people in their own homes will be subject to statutory regulation. As your Lordships will be aware, care in people's own homes is increasingly provided where in the past 13 admission to residential care would have been necessary. We welcome that trend. The introduction of regulation in this sector will be a huge step forward in improving quality and safety for people who rely on such services.
The importance of protecting vulnerable children is deeply felt throughout this House. The national care standards; commission will have significant responsibilities for safeguarding children. All types of children's homes will be regulated and subjected to rigorous inspections. This, again, will include local authority homes that are currently exempt and small private children's homes for fewer than four children.
The Bill will also introduce for the first time regulatory regimes for fostering agencies and for residential family centres. The national care standards commission will also regulate the crucial and specialised work of voluntary adoption agencies in a way similar to the current system operated by the Social Services Inspectorate. In recognition of its role in safeguarding children, the national care standards commission will appoint a children's rights director whose job it will be to ensure that children's rights and welfare are at the heart of all its responsibilities for regulating children's services.
The regulation of children's services must not be swamped by the much larger volume of adult services that the commission will deal with. The children's rights director will also provide a crucial function in being the person who will always he there for anyone to turn to when they have concerns or suspicions about what might be happening in a children's home or in other services. Too often, when scandals of abuse have been uncovered, children or staff members say that they knew something was not right but they were uncertain who to go to when they had concerns. I hope that we will not in future hear that people did not know who they could turn to.
The provisions in Part IV of the Bill establish a general social care council. Many people, including a number of your Lordships, have been calling for such a council for many years. We made it clear soon after coming to office that we would deliver on our long-standing commitment to establish the council, and this Bill keeps that promise. We have made it very clear, though, that the council will not be a body solely concerned with professionally qualified social workers. That would indeed be a missed opportunity. When the social care work-force numbers 1 million, 80 per cent of whom have currently no recognised qualification, we would be failing in our duties unless we set up a body whose concern went wider than the 50,000 most qualified members of that 1 million-strong workforce.
Professional social work and the system that underpins it will certainly be a crucial concern of the council, but it will oversee standards and training throughout the whole of the sector. Indeed, one of its first tasks will be to draw up codes of practice and conduct for social care workers and social care employers. These codes, the first of their kind in this 14 sector, will set out enforceable standards of conduct and practice expected of all those working in social care.
The general social care council will also register individual staff working on an incremental basis. With such low levels of qualifications, it will clearly take some time for the training in the sector to reach the levels where the majority of the workforce could be registered. For that reason the Bill also provides a mechanism to ensure that a social worker who has harmed someone in his or her care will not find his or her way back into the workforce.
Following the Protection of Children Act passed earlier this year, there is already a central list of people judged unsuitable to work with children. Part VI of the Bill introduces an equivalent measure for dealing with people who are unsuitable to work with vulnerable adults. I recall the concern expressed by many of your Lordships in debate that adults can be vulnerable as well as children. We have listened to those concerns and we agree with them. Nor is this measure confined to adults with a learning disability, which was the subject of our debate at that time. Any adult receiving care can be vulnerable, and the definition in the Bill is drawn accordingly.
I turn now to the Government's proposals for the regulation of child care, dealt with in Part V of the Bill. During our first two years in office we created as many child care places as the previous administration managed to create in 18 years. We will now build on those achievements. We recognise that for young people in particular the line between care and education is becoming increasingly blurred. Given this, reform of the regulatory regime for day care and childminding is important. The Bill will transfer responsibility for regulation from individual local authorities to a national body. We have decided that this will be a new, distinct arm of Ofsted.
Bringing together the regulatory systems for child care and nursery education will not only help create greater coherence and integration but will also lead to improvements in the quality of early years service. Establishing national standards for Ofsted to operate will ensure that child safety will no longer be a matter of geography but one of consistency across all of the country. The present system has become, in effect, one of localised regulation. This has led to widely varying interpretations in different parts of the country. A national framework will help to ensure a level playing field for all providers and will deliver clarity for both the regulated and the regulator.
We are also using this opportunity to make other improvements. Importantly, for the first time the Bill allows for new duties to be placed on those involved in looking after children aged between eight and 14, or 16 in the case of disabled children. These providers will be required to demonstrate that they and their employees are suitable people to look after children.
Taken in total, these measures will radically reform the regulation of child care. This is a crucial step towards creating a level playing field for public, private and voluntary sector providers. More 15 importantly, they will give parents greater peace of mind knowing that their children are being properly cared for, and our children will benefit for many years to come.
Before I conclude, I should like to say a few words about the arrangements in Wales. All of the provisions in the Bill apply to Wales as well as to England. In keeping with the devolution settlement, the National Assembly for Wales will be responsible for the functions that are conferred in respect of Wales. In Wales, the responsibilities of the national care standards commission will be carried out by the Assembly itself. The Bill establishes a care council for Wales which will match the general social care council in England. For the regulation of early years provision, there will be a formal partnership arrangement between the National Assembly, which will regulate the child care services, and Estyn, the Welsh equivalent of Ofsted.
These arrangements, which follow separate consultation exercises carried out by the Welsh Assembly, will mean that the same objectives and principles will be met in Wales in a way that suits the needs and circumstances of Wales. That, of course, is the purpose of the devolution settlement. I believe that the Care Standards Bill is an example of that settlement working in practice.
The Bill will provide modern, reliable arrangements for protecting the welfare of vulnerable people. It will put in place rigorous and coherent regulatory arrangements. As well as safeguarding people against abuse, it will promote high quality standards. It will revitalise the social care workforce and provide it with the recognition that it deserves. It will benefit staff; it will benefit those who run care services; and, most of all, it will benefit those who depend on those services. I commend the Bill to the House.
§ Moved, That the Bill be now read a second time.—(Lord Hunt of Kings Heath.)
§ 3.17 p.m.
§ Earl Howe
My Lords, the House has reason to be grateful to the Minister, for the second time in less than a week, for a lucid and balanced explanation of an important Bill. This Bill, though, unlike the one that we debated last Tuesday, scans a particularly wide horizon. It concerns itself not with a restricted range of public services provided to a small though deserving minority, but rather with the entire scope of activity embraced by the term "social services" and with a whole lot more besides, including acute and long-term healthcare. In so doing, it speaks directly to the users of such services, and potentially, therefore, to every single one of us.
On this side of the House we recognise the concerns that have led the Government to bring forward such a far-reaching measure. They are concerns that we share. Children and vulnerable adults in all too many reported cases have suffered from abuse and neglect. No one has a clear idea of what standards of care should be aspired to or treated as the norm in 16 residential homes, nursing homes, children's homes or boarding schools. The regulation of these various kinds of establishment is governed by a veritable patchwork of arrangements that nevertheless fail to be all-embracing. Standards vary according to where you happen to be, as do the costs of providing very similar services in similar parts of the country. Some 80 per cent of the entire social care workforce have no recognised qualifications or training. In the independent acute sector the arrangements for inspecting and enforcing standards in hospitals and clinics are woefully out of date and, in some cases, non-existent.
It is quite plain that if these concerns are to be tackled effectively, it will be necessary to underpin any new arrangements by means of regulation. The independent acute sector has indeed been pressing for such regulation for years. The Bill that we are now considering embodies that aim. But if we decide to regulate, there are several points that we need to remember. The first is that any regulation carries with it a burden of cost. Therefore, regulation must not only have a beneficial purpose; it must also be framed and implemented in a way that is cost-effective and not overly burdensome to those directly affected by it.
The second point that we need to bear in mind is that a piece of regulation that sets standards of good practice must focus on the standards that really matter and make sure that all those within its natural purview are treated in a consistent and uniform way. In the present case one of the things that we are trying to avoid is the "unlevel" playing field—and a playing field where half the time the referee is off the pitch. When we have finished regulating we do not want to find a pitch which is still obviously unlevel and a game that cannot proceed because the referee spends all his time blowing the whistle.
Perhaps I may say at the outset that we on these Benches are able to issue a cautious welcome to a fair proportion of this Bill. But we have to recognise that the Bill is in large measure an empty box. It establishes a legislative framework with little indication of its content. That of itself may not be a cause for complaint—indeed, it may be unavoidable—but it leads to the unfortunate consequence that we can only debate headlines and not detail. The devil will lie in that detail and we shall not be made aware of it until such time as the succession of statutory instruments is laid regrettably, I have to say, under the negative procedure.
One important set of such important regulations will be those that emerge from the consultation exercise that is currently in train under the title "Fit for the Future?" on the national standards for residential and nursing homes for the elderly. I have little doubt that we can devise a way of debating some of these detailed proposals in Committee should we wish to do so.
However, the debate is bound to be inconclusive because until the consultation period has ended there is nothing that the Minster can say by way or reassurance to us beyond the broadest of 17 undertakings. That is why I have to sound a note of deep unhappiness over this Bill, not in the first instance over its content. but over the timing of its introduction. We really ought to have the draft regulations in front of us as we debate it so we can see what it will mean in practice. I shall say more about where that leads us in a few moments.
What then of the content? I fear that there are a fair few criticisms that I wish straightway to lay at the Government's door. The first is that in one or two important respects they have retreated from the positions that they adopted, in largely reassuring terms, in their White Paper of November 1998, called Modernising Social Services. That document recognised a critical fact about social services: that they are a local service that varies from one part of the country to another in response to differing local needs and circumstances.
In recognition of that it was originally proposed that in England there should be eight regional commissions for care standards based on the boundaries of the NHS and social care regions. That proposal has been abandoned in the Bill in favour of one national care standards commission covering the whole of England. I question the wisdom of that change. The big advantage of autonomous local boards would have been their understanding of the particular needs and circumstances of their own areas—for example, in the context of health improvement programmes— and the ability to draw their board members from representatives of users and providers in the locality.
As it is, I confess to a feeling of inner dread at the creation of a single national body issued with a truly gigantic remit, which will find it all too easy to issue edicts from a position of lofty eminence and which will all too readily come to be regarded as being remote from reality.
The White Paper also spoke about achieving greater consistency of standards across the board, with users and providers knowing exactly where they stand. I have every sympathy with that aspiration. But what are we to make of it when we find that apparently in the acute sector NHS pay beds are to be excluded from regulation? What are we to make of it when we see that day care services for adults are also omitted? Exclusions such as these make a nonsense of the so-called level playing field when a person lying in one bed or sitting in a particular chair is covered by regulatory standards and by a regime of inspection and enforcement, but a person lying in a similar room nearby or sitting in the next chair, is not. I worry about the fact that the regulation of acute hospitals has been lumped in with nursing and care homes. It is almost unbelievable that acute surgical activity should be overseen by the same body as regulates residential and nursing homes.
But I am sorry to say that I believe I know the reason. The lively debates that we had in this House during the passage of the health Bill revealed a concern shared by many of your Lordships that the Government have a duty to establish a regulatory regime to protect all patients, whether they choose to 18 use the NHS or the independent sector. Both the NHS and private hospitals should be subject to the same duty of quality and to equivalent standards of clinical governance. Yet, as I read the explanatory notes, the care standards commission appears to have but a single focus; namely, care standards. It seems that clinical standards are outwith its remit. I am disappointed and depressed that the Government have not seized this golden opportunity to make the clinical quality agenda a reality for all patients.
As we debate this Bill, it is the patient, the service user, the elderly resident in a home and the child in care whom we need to keep at the front of our minds at all times. Everything that appears in this Bill or arises directly out of it, must be for the benefit of those people. That may sound like a statement of the blindingly obvious, but it is a message that, if the Government are not careful, they may lose sight of. My heart sank as I read the first set of detailed draft standards relating to residential and nursing homes for the elderly. These are some of the suggested standards: single rooms in current use must have at least 10 square metres of usable floor space or 12 square metres for wheelchair users. New single rooms must have at least 12 square metres of usable floor space. Each room must have overhead and local lighting; two chairs, at least one of which is an armchair. There must be enclosed space for hanging clothes, a TV aerial point, at least three accessible double electric sockets, and so on.
As regards nursing requirements, it is proposed that in the morning there should be ratios of five residents for each member of staff; seven to one in the afternoon and 10 to one at night, with additional staff on duty at peak times of activity.
What kind of brave new world are we in? It is prescriptiveness gone mad. It is an approach which reveals that the plot has been totally and utterly lost as regards what "care" actually means. Worse still, it is likely to prove devastating to the viability of many hundreds of nursing and residential homes throughout the country.
Perhaps I may quote some of the comments about this. The first is from the nursing director of the Registered Homes Association. He says,It is not about how many nurses you have got, it is the skills of those nurses that are important. Standards must be meaningful and concentrate on quality, not merely on physical standards".The next quotation is from a residential home proprietor in the south west. He says,I have difficulty comprehending how an increase in bedroom size can have that great an effect on the care and well being of our residents. The vast majority spend no waking time in them whatsoever. These standards would bankrupt us. Eighteen residents would be homeless. Twenty four staff, many of them breadwinners, would be unemployed".Yet another pointed out that the only way he would be able to increase the usable floor space in bedrooms would be to rip out en suite toilets which he has just put in at considerable expense. Work like that is as absurd as it is unaffordable. Indeed, in a survey carried out by the magazine Caring Times, in which 400 care homes of all sizes took part, it was shown that no fewer than 19 54 per cent of all beds and 49 per cent of jobs would be lost immediately if the standards in Fit for the Future? were introduced. More than 50 per cent of respondents said that they would be forced to close due to bankruptcy. The Department of Health has estimated that if the draft standards were to be applied now, without any transitional period, 20 to 23 per cent of independent sector residential homes would not meet the space and amenity standards; 12 per cent of nursing homes and 55 per cent of local authority residential homes would not do so. Furthermore, 53 to 56 per cent of nursing homes would not meet the staffing standards. Noble Lords should note that the public sector as well as the independent sector would be affected.
The real world is out there. Those who live in it feel that the regulations about to descend on them have been invented by inspectors for inspectors, without any heed to the meagre income levels of many residential homes which are barely enough to pay staff, let alone to service capital. I should add in passing that these income levels are a direct result of totally inadequate revenue support grant settlements that in turn directly affect fee rates.
To return to my comments of a moment ago, all regulation brings with it a burden of cost. From where is the money to come to upgrade all these homes, if that is what the Government are determined to insist upon? Unless a little sense is knocked into the process by Ministers—and there is still time to do that—the consequences in human terms and for social services will be dire. I do not know whether the Minister is aware of the pall of uncertainty that has been cast over the industry as a consequence of these proposals. Owners of nursing or residential homes cannot take out a mortgage unless they are either extremely lucky or they sell their properties. One correspondent recently described the situation as a blight.
The key indicators in assessing standards of care may not be those that are easy to measure, but they are the ones that matter; namely, the quality of the overall care experience. Somehow the Government must get closer to those indicators. In doing so, they must remember that the needs and preferences of service users are diverse. It is salutary to remind ourselves of one of the critical paragraphs in the White Paper, paragraph 4.48, which I shall quote in part:too much national prescription can lead to bad regulation. The key objective must be to develop a limited range of standards to apply at national level, with a certain degree of flexibility allowed more locally. These standards will focus on the key areas that most affect the quality of life experienced by service users … [and] will need to have regard to costs and effectiveness when they are being developed".Those are the principles that underpin the national service frameworks and, by sticking to them, Ministers can keep this show on the road.
The Committee stage of the Bill will lead us to examine a great deal of detail that is as yet unclear, including the commission, its composition, powers and duties, its cost and procedures. We shall have many questions to ask on the general social care 20 council, the implications of the blacklist procedures, the repeal of the Nurses Agencies Act and much more. However, for now I shall conclude by expressing my hope that, as so often in the past, your Lordships' House will perform its role as a scrutinising Chamber to good effect. On these Benches we look forward to playing our part in that process and ensuring that we make this important Bill a better one.