HL Deb 10 January 2000 vol 608 cc403-21

3.7 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath)

My Lords, I beg to move that the House do now resolve itself into Committee on this Bill.

Moved, That the House do now resolve itself into Committee.—(Lord Hunt of Kings Heath.)

On Question, Motion agreed to. House in Committee accordingly.


Clause 1 [Children's homes]:

Lord Hunt of Kings Heath moved Amendment No. 1: Page 1, line 9, leave out ("subsections (3) and (4))") and insert ("the following provisions of this section)").

The noble Lord said: In moving this amendment I shall speak also to Amendments Nos. 2 to 4 and 149 and 150. They are correcting amendments to re-enact the provisions of the Children Act that require boarding schools in certain circumstances to be registered also as children's homes.

Section 63 of the Children Act requires independent boarding schools to register as children's homes where they provide or arrange accommodation for any child for more than 295 days a year. The Bill as currently drafted states that if an establishment is a school, it cannot also be a children's home. These amendments are therefore necessary in order to retain the current provisions contained in the Children Act.

We consider it appropriate that the more stringent arrangements for registering children's homes should apply where children remain with the school for much longer periods than are covered by the normal school terms. Consistent with the new definition of "children's homes", there will no longer be an exemption for schools providing accommodation for fewer than four children. In addition, the amendments cover independent schools approved for the education of children with special educational needs which are not currently provided by the Children Act provisions. We consider that such schools, where they provide accommodation for children for more than 295 days in a year, need to be registered as children's homes in the same way as other boarding schools.

The amendments allow an important set of safeguards for children accommodated away from home to continue under the new arrangements provided for by the Bill. I beg to move.

Lord Northbourne

I should like to express concern about the definition of these schools as set out in Amendment No. 3. Will the Minister indicate whether the purpose of the clause is to protect particular children at a school? If that is so, I suggest that the amendment is not worded clearly enough. Some schools take in other children for holiday courses, which could easily extend over the 295-day period. The children who attend the school during the normal term time are one group and an entirely different category of children may attend during the holidays. For example, at a school with which I am familiar music courses are held during the holidays. Some clearer definition may be necessary in that respect.

Lord Laming

In regard to Amendment No. 2, leaving out the words from "centre" to the end of line 8, what is a "residential family"?

Lord Hunt of Kings Heath

In regard to whether the definition of "295 days" is appropriate, there is no intention to capture schools with normal terms which run residential courses during the holidays, as many do. As regards the definition included in the clause, the key reference is that the accommodation is provided for children for more than 295 days. I take that to mean children receiving schooling for more than 295 days in any one year, rather than a school using the holiday period for other children's holiday activities. The provision repeats the wording of the Education Act. I am satisfied that it does not need further clarification. However, I shall be happy to examine it in the light of the noble Lord's comments.

Lord Clement-Jones

I thank the Minister for having had the courtesy to write to me about one of the amendments that he has tabled. His case is clearly that the provision in the Bill is largely a reintroduction of provisions included in the Children Act but with the exception of independent schools approved for the education of children with special educational needs. What consultations have taken place with such schools about the provisions? After all, this is a major new piece of regulation for them.

Lord Jenkin of Roding

Perhaps I may take up the point made by the Minister in his reply to the noble Lord, Lord Northbourne. He said that it is not the intention of the clause to catch, for instance, schools that run music courses during the holiday. However, it may be desirable to reflect that point in the Bill rather than merely in a statement from the Front Bench.

On another point, independent schools are increasingly taking pupils from overseas. It is by no means unknown, particularly in the shorter school holidays, for some of those pupils to remain at the school, possibly being looked after by the family of one of the masters, during the Christmas and Easter vacations. In tho3e circumstances a school may find itself with several children who are there for more than 295 days. Would that convert the school into "a children's home", whereas otherwise that would not happen?

3.15 p.m.

Lord Hunt of Kings Heath

Perhaps I may deal first with the issue of special schools. We are extending the dual registration arrangements to cover independent special schools, which are not currently covered. That will bring a further 100 or so special schools into the regime. That is an important safeguard. Children who attend such schools will receive the extra protection provided by dual registration.

As regards the more general issue raised by the noble Lord, Lord Jenkin, I have said that I will reflect on the point raised by the noble Lord, Lord Northbourne, to make sure that the definition contained in the amendment does not cause problems to schools which use school premises outwith school term time. I repeat that the wording in the amendment follows current legislation. I am not aware that the present law has caused any problems to individual schools, either in the terms in which the noble Lord spoke or in terms of the point raised by the noble Lord, Lord Jenkin, regarding people coming from abroad who might stay in school premises.

Baroness Masham of Ilton

I am very pleased that special schools have been included, but why were they not included in the first place? It is well known that some of these schools were strongly considered to be at risk and that serious abuses have taken place throughout the country.

Lord Hunt of Kings Heath

It would be difficult for me to explain why special schools were not included in legislation that was enacted some years ago. The noble Baroness is right to point out the importance of introducing the safeguards into this Bill.

As regards the point about independent schools in relation to children with special needs, the originating concern came from the children's safeguards review. In reply to the noble Lord, Lord Clement-Jones, we have not yet held detailed discussions with the schools affected. However, I assure the noble Lord that we shall discuss detailed arrangements with them in due course.

Lord Laming

Will the Minister indicate what the term "residential family" means?

Lord Hunt of King's Heath

The amendment is not aimed at omitting the word "centre" but the word "or". It is a drafting point in order to introduce a new definition of a dual registration school.

On Question, amendment agreed to.

Lord Hunt of Kings Heath moved Amendment No. 2: Page 2. line 7, leave out from ("centre") to end of line 8.

On Question, amendment agreed to.

Lord Hunt of Kings Heath moved Amendment No.3: Page 2, line 9, at end insert— ("(5) Subject to subsection (6). an establishment is not a children's home if it is a school. (6) An independent school is a children's home at any time if at that time accommodation is provided for children at the school and either—

  1. (a) in each year that fell within the period of two years ending at that time, accommodation was provided for children. either at the school or under arrangements made by the proprietor of the school, for more than 295 days; or
  2. (b) it is intended to provide accommodation for children. either at the school or under arrangements made by the proprietor of the school, for more than 295 days in any year;
and in this subsection "year" means a period of twelve months.").

On Question, amendment agreed to.

Clause 1, as amended, agreed to.

Clause 2 [Independent hospitals etc.]:

Lord Clement-Jones moved Amendment No. 4: Page 2, line 12, at end insert ("and for the purposes of this Act an independent hospital shall include private patient units within a health service hospital").

The noble Lord said: I beg to move Amendment No. 4, the purpose of which is very similar to that of the two following amendments and the amendment in the name of the noble Earl, Lord Howe, and noble Lords on these Benches. I am sure that the noble Earl will have more to say on the subject. This is perhaps a fairly crude amendment but it is designed to deal with the straightforward question of whether or riot NHS pay beds should be subject to regulation under the terms of the Bill. Currently, such beds are not subject to review by the Commission for Health Improvement under the Health Act which we debated some months ago. This amendment is designed simply to bring into the fold those NHS pay beds which, after all, should be treated on the same footing as those provided by any other independent healthcare provider. If they are not brought within the terms of the Bill, no form of inspection or review will be applicable to them. What guarantee can patients in those NHS pay beds have of good clinical practice?

I am very happy to see NHS trusts raise further funds by the provision of NHS pay beds. It is good to have a "mixed economy" in that sense. But I believe that one of the key matters in this Bill—as it was when we debated the Health Bill (now the Health Act)—is quality. The professions are themselves putting their house in order in terms of clinical governance. I believe that the Government in turn should ensure that the inspection and review regime is seamless not only across the NHS and the private sector, but also within the private sector. Both the private care sector and consumer interests believe strongly that that is a glaring omission. This particular amendment has been proposed by consumer organisations which feel strongly that, for the sake of the patients, Amendment No. 4 should be accepted by the Government.

Earl Howe

I rise to speak to Amendments Nos. 11 and 18 in my name and to support strongly the observations of the noble Lord, Lord Clement-Jones. The Government are in a terribly complicated muddle over the regulation of private healthcare. The delivery of healthcare in this country does not issue forth from two conveniently separate channels, one labelled "public" and the other "private"; it is not as simple as that. The NHS frequently sub-contracts to the private sector, most notably in the field of mental health, and there are private wings and beds in NHS hospitals. If one decides, as the Government appear to have done, that, despite all the interdependence between the public and private sectors and the facts that most consultants work in both sectors and that the same patient can be treated in one sector and moved to another for further treatment, the public sector is to be regulated in one way and the private sector in another, anomalies are bound to occur.

My understanding based on the debates last year on the Health Bill was that the Commission for Health Improvement would be the regulator of all healthcare funded by the public sector, including care delivered to NHS patients in private hospitals. We shall deal with that anomaly when we debate Amendment No. 31. Meanwhile, I should like to hear from the Minister whether my understanding is correct. Now that we are about to have a national care standards commission with a separate division responsible for regulating private hospitals and clinics, are we to suppose that in practice CHI may sub-contract to the commission the job of overseeing NHS patients in private hospitals?

The anomaly addressed by this amendment, however, relates to NHS pay beds. Many people, including myself, are still unclear as to what role, if any, will be played by the Commission for Health Improvement in the supervision of standards in private wings and wards of NHS hospitals. The Minister was kind enough to address this issue in his winding-up speech at Second Reading, but I am afraid that I did not understand it, even on re-reading what he said. If CHI is not to be involved in the regulation of NHS pay beds, surely it follows that the national care standards commission must be; NHS pay beds cannot be left out in the cold.

The trouble with the Bill is that it begins by categorising different kinds of care services in terms of the physical premises that they occupy. That might have been the best that the lawyers could do, but it makes life awkward when part of the Bill is devoted to NHS care and part is related to private care. My amendments try to find a way through it by defining a new type of establishment; namely, an income-generating health service unit. Such a unit is, in other words, a private ward or wing of an NHS hospital. Under this proposal, the NCSC will assume responsibility for NHS pay beds alongside its responsibility for monitoring standards in private hospitals. I hope that that proposal is a logical one; certainly, it is meant to be constructive. I hope that the Minister will view that amendment with some sympathy.

Lord Jenkin of Roding

I find myself in difficulty in this matter. I do not know whether the Minister is old enough to recollect Cullompton. At the time of the debates about the continuation of private beds in NHS hospitals when the noble Baroness, Lady Castle, was Secretary of State, there was considerable argument about whether it was appropriate that there should be pay beds within the premises of NHS hospitals, sometimes as an integral part of wards. Happily, in the end, sensible provisions prevailed, although it may have taken a year or two for the system to settle down.

I find myself in a dilemma in this matter. I completely understand the point to which the noble Lord, Lord Clement-Jones, referred. I also understand the points made by my noble friend in speaking to his amendments. But pay beds take many different forms. I take as an example Lindo Wing at the Middlesex Hospital or units at other teaching establishments which have premises separate from the main NHS hospital. In those circumstances, the intention behind the amendment moved by the noble Lord, Lord Clement-Jones, is wholly appropriate. That should be looked after by the new commission. In the Forest Health Care Trust, of which I was chairman for a number of years, the largest group of pay beds was in that part of the hospital concerned with maternity. We found that over the years there was a considerable demand, even in a relatively deprived area of north-east London, for privacy and the ability to receive visitors at all times, and that people were prepared to pay for it. After all, nowadays most mothers are not in maternity beds for more than a day or two and therefore the cost is not very great. Those beds were an integral part of the remainder of the maternity provision in the hospital. The idea that somehow there should be two lots of inspection, one for NHS beds and the other for pay beds, seems to me to be utterly absurd. One must look at the remit of CHI and consider whether in those circumstances it is entirely appropriate that there should be a single system of inspection. For that reason, I find it difficult to accept these amendments.

There is another category: amenity beds. As I understand the language used by my noble friend's Amendment No. 11—"income-generating health service units"—an amenity bed, which is much cheaper than a private bed, generates income and gives some of the advantages of a pay bed without the full cost being borne. Would those beds be subject to a separate system of control? I find all of this hugely confusing. I cannot believe that the Government do not now share that view. There will be a ridiculously overlapping system of inspection for what constitutes a single provision of beds which are occupied by patients under different terms.

If one is looking for a way to inspect the standard of care—we shall debate clinical care in later amendments—one single inspection system must surely be right.

3.30 p. m.

Lord Clement-Jones

Before he sits down, perhaps I may ask the noble Lord to consider Amendment No. 31. What he said demonstrates much of the absurdity relating to acute healthcare. The contradictions in the Bill are exposed clearly in this set of amendments. Perhaps the noble Lord will agree that that may be a more felicitous way of dealing with regulations so that common standards are met in NHS and independent healthcare beds.

Lord Jenkin of Roding

Perhaps I may respond to the noble Lord. If that is the intention, I shall listen with great interest to those who speak to that amendment.

Baroness Masham of Ilton

I hope that a satisfactory solution will be found. I have been a patient in a National Health Service hospital which had private beds. I visited some of the private patients. Many were in side wards. They were foreign, lonely and deprived. I thought that they were being ripped off. Sometimes their rooms were not dusted. Sometimes they were overlooked and not fed. It would be wrong to leave such patients out of the debate. I hope that a satisfactory solution will be found.

Baroness Gardner of Parkes

It has been interesting to listen to the different aspects put forward. The debate has revealed what a complex issue we are discussing. For some time I was chairman of the Royal Free Hospital which has private beds within the main hospital occupying half of a specific floor. Because there was need for more beds, national health patients were always given priority and those beds were used regularly for NHS patients although the private beds generated a large amount of additional income for the hospital and there fore were of great benefit to the national health patients.

The noble Baroness, Lady Masham, raised the issue of shabby wards. The point may be true in some areas. If the private wings in London hospitals are not smartened up to a considerable degree, one has no hope of getting patients into them. They prefer the luxury hotel surroundings of the new, completely private clinics. One has not only to provide the best medicine but also luxury surroundings to encourage patients to choose one hospital rather than another.

I wish to raise a different aspect. I like the phrase about the income generating health service. Some major national health hospitals run travel clinics. Patients pay for the injections and so on, which they need for travel. Such clinics are not a national health service and never have been. Yet such treatment is given in those hospitals.

I am not clear whether the Bill relates only to inpatients who are resident in hospital or whether it will also provide for people having treatment of any form. With the present influenza crisis, many businesses would happily pay 'or that national health hospital to give influenza injections. The cost would be far less than that lost due to illness. It would surely be viable through the travel clinics. The premises already exist. It would be an additional feature.

We differentiate between what one can and cannot have. However, the patient or someone on his behalf may be prepared to meet the cost. When I was a parliamentary candidate for the Commons, I exchanged a number of letters about pay beds in Plymouth with the then Dr Owen. Pay beds have always been a major issue. However, I agree with the noble Lord, Lord Jenkin. It is important to have one standard and, if possible, one inspectorate. Could that be better achieved by inspection through the National Health Service? The noble Lord's point is valid. To inspect perhaps half a dozen beds or one minor clinic within the institution will not only be irritating but also somewhat impractical. Everyone will be on the defensive and much goodwill that exists in national health hospitals may be destroyed.

I do not know whether to support the amendment. The more I have listened, the more uncertain I am. It is important that the Government apply their mind to a solution.

Lord Rix

For 10 years I was a patient across the water at St Thomas' Hospital while my aortic valve, which was busily closing, was examined. Although taking advantage of the private facilities at York House across the road from St Thomas' Hospital, I was sent all the time to the national health testing beds in the hospital. Eventually I became an emergency patient and was admitted to the private rooms on the top floor of the hospital where, after further examination, the aortic valve was replaced.

For 10 years I mixed private care with national healthcare in that hospital. Yet it all took place on the same premises. I should have thought that an inspection by the same body was sine qua non.

Baroness Masham of Ilton

Perhaps I may respond to the noble Baroness, Lady Gardner of Parkes. The patients I saw had unfortunately no choice because they had broken their backs or necks. They were sent for treatment by foreign governments.

I hope that the Minister will visit soon the Stoke Mandeville Hospital where he will see the situation for himself. He will also see how important is the income generated by those patients. That may help him sort out the matter. Two inspections would be a waste of time and resources.

Lord Hunt of Kings Heath

The noble Baroness, Lady Masham, continually invites me to visit various excellent NHS facilities. I assure her that Stoke Mandeville is on my list.

The discussion takes us back to the debate at Second Reading and the distinction to be made between the need for the proper regulation of the private healthcare sector and the effective management of the National Health Service, including private facilities contained under its management. Far from there being confusion or a problem about distinction, everything contained in the Bill and as regards the regulation of the private healthcare sector rests on the premise that there will inevitably be different arrangements between the regulation of the private sector and the management of public sector healthcare services. We shall debate the issue more fully on later amendments. However, I felt that I should set the context in which we are debating the proper management of NHS pay beds.

Amendments Nos. 4, 11 and 18 seek to extend the national care standards commission's regulatory responsibilities to cover NHS pay beds and other income generating facilities. Amendment No. 4 would include NHS private patient units within the definition of an independent hospital in Clause 2 thereby bringing them under the remit of the commission. Amendment No. 11 would have the same effect but would also bring other NHS income generation undertakings within the commission's remit. Amendment No. 18 has the same effect.

In reply to the noble Lord, Lord Jenkin, I am not sure how widely the noble Earl, Lord Howe, intended the regulator's powers to go, because NHS trusts can generate income in a variety of ways. The noble Lord mentioned amenity beds, but one could include, for instance, renting out space to shops. I am sure that he did not intend to include such action within this provision.

I believe that the amendments are misconceived. They assume that NHS paybeds need to be subject to regulation because otherwise they would be subject to no control. That is not the case. NHS paybeds, including those in dedicated units, are the responsibility of the NHS hospital where they are sited. They will be subject to clinical governance and all the other controls which apply to the NHS. The amendments would mean that even though a perfectly good system of management and clinical governance covered the whole hospital, certain parts of the hospital would be subject to another regulatory regime. That would be duplicatory and wasteful of time and effort. It would also distract the national care standards commission inspectors from their key task of improving regulation of the currently poorly regulated private sector into inspecting parts of the NHS where perfectly good systems of clinical governance are in place.

Lord Clement-Jones

Will the Minister clarify those important words? Is he saying that NHS paybeds are covered by the Commission for Health Improvement; and that the reviewing body will be the commission? Will national service frameworks apply to NHS paybeds? Will the NICE guidelines be applied by the CHI when it is inspecting those paybeds? That is implied in the Minister's statement that the full regime as applied to the NHS will apply to its paybeds.

Lord Hunt of Kings Heath

That must be right because those beds are part of an NHS trust hospital. What applies to that hospital must apply to all the beds within it.In conclusion, I say to the noble Earl, Lord Howe, that I refute the muddle which he suggests we have fallen into. I reiterate the fact that NHS paybeds are already covered by clinical governance and that therefore there is no need to have them further regulated by the care standards commission. On that basis, I invite the noble Lord, Lord Clement-Jones, to withdraw his amendment.

Earl Howe

I am grateful to the Minister for clearing up much fog and uncertainty that have descended upon the issue. He has done so extremely clearly. We have had a helpful short debate and at the appropriate time I shall not move my amendments.

Lord Clement-Jones

I thank the Minister for clearing up one confusion. However, in clearing one fog another has descended. As was said by the noble Lord, Lord Jenkin, as some of the NHS paybeds closely equate to independent sector healthcare beds perhaps they should be regulated in the same way. However, as others, such as maternity units, closely equate to NHS beds, a common inspection regime should apply.

The common message is that a single set of regulations should apply across the board. The Minister repeated the distinction he made on Second Reading between the regulation of the independent healthcare sector and the management of the NHS. However, in many respects, it is a distinction without a difference. A common review and inspection system would be feasible, still leaving the regulation of the private care system within the commission. Future amendments are designed to achieve that.

We have had an interesting and well attended debate and I thank all Members of the Committee who have taken part. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

3.45 p.m.

Lord Clement-Jones moved Amendment No. 5: Page 2, line 23, after ("hospital") insert ("or any undertaking by one or more persons)").

The noble Lord said: Amendment No. 5 deals with a number of additions. We have tabled amendments to Clause 4, but this set of amendments has been formulated to fall under Clause 2. In a sense, therefore, we shall have two bites at the cherry in examining additional establishments which should be covered by the Bill.

A Consumers' Association report in Health Which?, published in August 1999, found that patients using private GP call-out services may not be adequately protected. One of the problems is that, because they are domiciliary services and are not based in a clinic-type setting, they may not be covered by the Bill. The amendment makes it clear that private call-out services must register under the proposed regulations.

I turn to Amendment No. 6. Arguably, dental care is the most common private healthcare service used by patients. While it is good that premises providing general practice services are covered under the Bill, we are concerned that only those dentists who provide treatment involving general anaesthetic will be regulated. We do not believe that that is adequate. Therefore, we propose that the dentists who do not provide general anaesthetic should also be covered. They can undertake invasive and high-risk procedures and therefore, like GPs, should be regulated. I beg to move.

Lord Hunt of Kings Heath

The purpose of Amendment No. 5 appears to be to seek to regulate medical practitioners who do not work from a specific establishment. We are concerned to ensure that the new regulatory system protects patients and have therefore decided to extend regulation to private primary medical care premises. We regard it as being extremely important that such premises, which include private walk-in clinics such as medi-centres, operate to clear standards and are properly and regularly inspected. Our aim is to ensure that all such premises are regulated without regard to their ownership arrangements.

Amendment No. 6 seeks to bring all private general dental practice within the scope of the commission's regulatory powers. I understand the thinking behind the noble Lord's proposal, but I believe that such an extension of regulation is unwise. First, most dentistry, whether practised in the private or public sectors, does not present a great risk to patients. The great exception is in relation to dentistry under general anaesthetic, which has tragical ay resulted in deaths.

We are determined to regulate such property, and the Bill makes provision for the commission to regulate premises where that work is undertaken. Furthermore, Clause 37 will allow such treatment to be regulated under the existing legislation even before the commission comes into existence, so concerned are we to take action.

However, I must say to the noble Lord that it is a big step from regulating this aspect of dentistry to regulating the whole of private dentistry. We consulted on the issue last year and carefully considered the results. We concluded that it would not be right to extend regulation in the way proposed, not least because of the need for proportionality in our approach and the need to avoid unnecessarily increasing the regulatory burden on small businesses. That said, we stated clearly in Regulating Private and Voluntary Health Care chat we shall keep the matter under review and consider whether at some stage we should extend regulation to that and other sectors.

The noble Lord, Lord Clement-Jones, raised a specific issue concerning call-out services. All wholly private GPs will be covered. Therefore GPs would be covered wherever 'they were practising. We did not regulate only the premises. It is worth making the point that private GPs will also come under the regulatory provisions of the General Medical Council.

Baroness Gardner of Parkes

I should like to pass some comments on the Minister's remark that he does not believe that much dental hazard exists except in cases involving dental anaesthesia. As a dentist who has used thousands of general anaesthetics I believe that the general anaesthesia issue has gone over the to pat present. I feel strongly about all the poor children who have to wait three months before they may have anything done.

There is a further aspect to the matter. At the time when I was in practice the National Health Service was very much stronger than it is now. I deplore the transfer of dentistry away from the National Health Service. I was a member of the London local dental committee, and a procedure existed whereby we used to inspect any surgery or premises where there was any doubt whatever about the standard of cleanliness or hygiene. Today, when sterilisation is a most important feature of life in terms of transmission of infection—particularly HIV, although hepatitis is perhaps even more transmissible—it is important to ensure that all dental practices have adequate facilities in terms of autoclaving.

In my day when one started one used to mix up one's solution in a bottle of water and add the tablets. Nowadays people would be horrified by that. Unfortunately, disease has progressed to the extent where it is terribly important that one has a sealed individual capsule and an individual needle. The Minister might believe that practices do not act in such a way, but I recall clearly, when I sat on the disciplinary committee of the General Dental Council, the case of a NHS practice—it could now he a private practice—where the forceps were merely dipped under the tap after each extraction. The dentist concerned had a turnover of £1 million per year and was disqualified by the General Dental Council. Think of how many patients he had treated without sterilising anything. He had one set of forceps for four surgeries which he would dip under the tap and then run on to the next patient. The hazard of that to the patient is almost unbelievable.

Therefore, I cannot go along for a minute with the view that the only hazard in dentistry is general anaesthesia. It is important to consider this question. If I could find fault with the amendment tabled by the noble Lord, Lord Clement-Jones, it might be that to specify dental practitioners is not enough and that the amendment should refer to premises used by anyone in any allied profession. I do not know what the hazards are in an osteopathic or chiropractic practice. Perhaps the terms of the amendment are not wide enough, but it would certainly be a good thing to include dental practitioners, unless the Minister can assure me of some other form of examination being carried out to assess standards in private dental practice.

Baroness Masham of Iton

Will the Minister tell the Committee whether, where line 24 of Clause 2 states, "by medical practitioners", nurse practitioners are included?

Lord Hunt of Kings Heath

I believe that the answer must be no.

It is a foolhardy Minister who tries to talk about dentistry when the noble Baroness, Lady Gardner, is in the Committee. She made some extremely valid points. I hope that I did not, by saying that the particular focus here relates to anaesthesia, give the impression that other issues do not need to be considered in relation to safety and hygiene within dental premises. The substantive point that I was trying to make is that this is an area of particular concern. I note the noble Baroness's comments as to whether too much is made of the anaesthesia issue. Certainly we in government have been concerned about the number of cases identified where use of anaesthesia has led to deaths in dental surgeries. The noble Baroness may well be aware that we are currently undertaking a review of that matter.

To move from regulating that aspect of dentistry is a large step and it seems to me sensible to focus on that area. In relation to the more general issues about dentistry raised by the noble Baroness, we hope to publish a strategy on dental services in the future as part of our efforts to try to ensure that those who wish to have NHS dentistry may receive it. Of course, GDS regulations exist in relation to NHS dentistry which are one component of the relationship between the NHS and dental services. We are keen to encourage such practices as continued education for dentists in order that we may update them and ensure that they keep up with current thinking and trends.

Lord Clement-Jones

Before the Minister sits down I should like him to answer a question. Is dentistry carried out in care homes subject to a different regime or is it still subject to the same regime—that is, that such dentists are regulated only when operating under general anaesthetic?

Lord Hunt of Kings Heath

I believe that that is right. I shall check the point and perhaps write to the noble Lord. In relation to dental services, the Bill certainly focuses on treatment under anaesthesia.

Lord Clement-Jones

I thank the Minister for a number of assurances he made during his reply, in particular in relation to the long-awaited dental strategy. I have asked a number of questions on that point and it is probably now about 18 months overdue—that is merely a quick estimate of the period of time for which we have been awaiting it. We look forward to it because it should clarify some of the issues.

Lord Hunt of Kings Heath

We hope that the strategy will be published shortly. It is always better to get it right than to rush it.

Lord Clement-Jones

There can be no danger of the strategy having been rushed, so I am sure that it will be an excellent strategy once it arrives. I appreciate also the Minister's assurance that, although he does not agree that dentistry in general should be brought within the scope of the Bill, there will be a review. I must say that I found some of the points made by the noble Baroness, Lady Gardner of Parkes, rather telling. I ask the Minister to read Hansard and to consider whether that review should happen sooner rather than later. Clearly dental interests need to be consulted, but I suspect that, as so often happens in such cases, the better private practice dentists would welcome such regulation and only the worst practitioners would not welcome it, just as all the reputable independent healthcare sector organisations have welcomed greater regulation over their activities.

Finally, I thank the Minister also for clarifying the position relating to private general practitioners. That will be a matter of some considerable comfort because it was felt that the Bill did not cover those who did not practise out of a clinic or out of their own premises. As the Bill goes through the House, we shall no doubt consider further the question of dentists who do not carry out general anaesthetics and we shall take on board some of the points made by the noble Baroness, Lady Gardner. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 6 not moved.]

On Question, Whether Clause 2 shall stand part of the Bill?

Lord Laming

The debate on Clause 2 has been extremely helpful because it has revealed all too clearly the anomalies which the clause introduces into an otherwise very worthy Bill. The contributions made by a number of noble Lords have indicated well and truly that the inclusion of Clause 2 clarifies one anomaly but creates another.

As I indicated at Second Reading, overall I warmly welcome the Bill. The main reason I do so is because it ensures for the first time that whoever is the provider—local authority, voluntary body or independent organisation—all social care provision will be regulated and inspected by the same body according to the same standards. That kind of consistency is warmly welcomed. But it is torpedoed by the introduction of Clause 2. Whatever the connection between the care standards covered by the rest of the Bill and dental services that use anaesthesia, clinics that terminate pregnancies, obstetrics services and cosmetic surgery and so on, Clause 2 is in the Bill only because the services referred to within it are independent or provided independently of the National Health Service. However, the issue of pay beds within the National Health Service and some other points which have been made, especially by the noble Baroness, Lady Gardner of Parkes, and the noble Lord, Lord Clement-Jones, have indicated that those lines of demarcation are far from clear.

The national care standards commission will be an entirely new body with a huge range of responsibilities in the social care field. It will register thousands and thousands of centres and individuals who must be deemed fit to run such services. The services will cover the whole age range and an enormous variety of needs experienced by children, adolescents, people with learning disabilities or those with mental health problems, physical disabilities or problems associated with ageing. The commission will already need to employ a wide range of people with specialist knowledge and skills if it is to achieve its principal function; that is, the registration and inspection of care standards. It seems to me totally unrealistic to believe that a whole range of other skills necessary to deal with anaesthesia, anaesthetics, palliative care, cosmetic surgery and so on can be grafted on to that body. The Bill goes some way towards acknowledging those difficulties in that standards for the inspection of care services appear to be different from the standards applied to health provision.

I have great regard for the Minister and for his knowledge of health services. He comes from Birmingham. When he addresses the good people of Birmingham he will be able to tell them that wherever their relatives are placed in the social care system, because of the Bill the standards will be secured by a uniform system of registration and inspection. However, sadly, because of Clause 2, he will not be able to say the same about healthcare. Within Birmingham is a vast reservoir of specialist knowledge and skill across the whole range of health service provision. However, that skill and knowledge are within the National Health Service and should be applied wherever the provision is made. As several noble Lords have said, increasingly the National Health Service is using independent provision in a wide range of ways; sometimes for recuperation, sometimes for rehabilitation, and sometimes because there is insufficient provision in the health service and therefore the choice is made to use an independent provider. It is not sufficient to say that the use of independent providers will be dealt with on a contractual basis with contractual arrangements. Everyone must be assured that the standards which apply in one section of healthcare will apply in all sections.

I happen to be a great supporter of the National Health Service. However, I believe that wherever people receive healthcare treatment the standards of regulation and inspection should be the same. I do not believe that there is a sufficiently good argument for separating this area of activity from the remainder of the health service and for saying simply that the National Health Service is managed by the department. Whoever manages a service, that service should be subject to the same system of regulation and inspection. Unless the clause is removed from the Bill we shall have anomalies, of which pay beds in the National Health Service is just one.

Your Lordships will recall the long debates which took place in this House on the Health Bill and the detailed discussion about new ways of promoting and maintaining clinical standards and monitoring performance across the health service. In addition to the long-established systems within healthcare, there are now adequate ways to ensure that all healthcare, whoever provides it, can he regulated, monitored and inspected by one body. I was interested in a publication which I am sure your Lordships will have seen. It is a recently published Parliamentary Brief in which the Secretary of State for Health, Mr Alan Milburn, states: For the first time in the history of the NHS we are setting clear national standards—through National Service Frameworks and the National Institute of Clinical Excellence—to guarantee fair treatment wherever patients live". Of course, wherever patients live; also, wherever patients are provided for. Mr Milburn goes on: And for the first time we are inspecting all parts of the health service—through the Commission for Health Improvement—to ensure that patients get the top class care they deserve". I agree with that. However, if all aspects of the health service are to be inspected through the Commission for Health Improvement, surely it is possible to ensure that other health providers can be subject to the same type of inspection.

In my view, Clause 2 undermines the consistency of an otherwise extremely worthy Bill. If the clause remains, it will undermine public confidence in the safeguards for patients and patient care and treatment and it will complicate unnecessarily the task of the new care standards commission. I believe that it will put at risk the commission's effectiveness which, in the long term, will undermine its performance. I hope that your Lordships will take this opportunity to remove Clause 2 from the Bill.

Lord Clement-Jones

I support the noble Lord, Lord Laming. I believe that I would have only to say, "Amen", and my task would be done. However. I repeat some of the questions raised by the noble Lord. He expressed the issues extremely eloquently. He quoted the Government against themselves. I believe that the only matter he did not mention was the Government's own conclusions in response to the Health Committee which, again, can be prayed in aid against them. As we go through the Bill, the contradictions posed by Clause 2 will become greater and greater.

As the noble Lord, Lord Laming, said, the provisions concerning independent acute hospitals have simply been grafted on to the Bill. Those of us who have been struggling with amendments during the recess have become acutely aware that the provisions regarding the regulation of independent care in the acute sector are simply bolted on and do not fit at all comfortably with the remainder of the Bill. The Bill is highly progressive and, as the noble Lord, Lord Laming, said, will provide consistent regulation across the social care sector. We see no such thing arising from that in the healthcare sector. Rather, we see a very different set of regulation. The best solution would be to get rid of Clause 2.

The Minister is known for his reasonableness. We had good discussions concerning almost everything relating to the Health Bill apart from the independent healthcare sector. That was the one area where we divided continuously. We did not play a great deal of "ping-pong" but we divided continuously from Report stage through to Third Reading and got no joy whatever from the Government. I cannot help believing that there is some ingrained ideological unwillingness inside the heads of Ministers who, although they proclaim the virtues of a mixed economy in social care, somehow cannot grasp the fact that we have also, albeit on a more limited scale, a mixed economy in healthcare. After all, only this morning the Secretary of State spoke about how the flu epidemic is being dealt with. He was trying to refute those who say that the independent healthcare sector is not being used sufficiently to deal with the epidemic. He said that we have contracts between local trusts and health authorities and the private healthcare sector. Therefore, in practice there is use of that sector. It is high time the Government responded to what is absolute common sense in this matter and agreed that we have a seamless system of regulation of healthcare across both the private and the NHS sectors.

Lord Hunt of Kings Heath

I fully understand the reasons why the noble Lord, Lord Laming, does not want the national care standards commission to regulate the private healthcare sector. But we are determined to strengthen the current regulatory arrangements for this sector, not least to ensure the quality of care for patients. We believe that the most effective ways of doing that are contained within the proposals in this Bill.

It is clear that we shall have further debate on this subject later tonight and indeed as the Bill progresses. But before responding directly to the noble Lord, I should set out the Government's general approach to the regulation of private and voluntary healthcare.

We believe that the starting point is that those who operate private hospitals should be accountable for all aspects of care undertaken in them—both the clinical and the non-clinical services. This includes the work of doctors to whom they grant admitting rights. It is not acceptable for hospital owners and managers to seek to wash their hands of their responsibilities on the grounds that patients contract separately with consultants for medical care.

We believe that there should be a strong regulatory regime for private healthcare. There is no doubt that one of the many weaknesses with the current regulatory regime is that 100 different health authorities are responsible for inspecting private hospitals. I believe that that has led to an inconsistent approach and that some health authorities have found it very difficult to regulate private hospitals appropriately.

We believe that establishing a single body, the national care standards commission, with responsibility for regulating private healthcare across the country, will ensure a consistent and clear approach to enforcing the standards that we set. The inspectors will be focused on the healthcare sector and will develop the expertise and skills necessary to ensure proper regulation of this sector.

I know that the noble Lord would like to have a separate body—or I suspect the noble Lord would like to have a separate body—regulating the independent healthcare sector. This would have been appropriate when the Government planned to have regional commissions for care standards, as there would not have been the same expertise at regional level nor the same need for regulating private healthcare in some areas as opposed to others. But as we have decided to have a national commission, that is no longer the case. Her Majesty's Government very much believe that having one body regulating all the areas encompassed in the Bill is the best way forward.

Having one body regulating healthcare alongside social care will mean that the commission will be able effectively to regulate facilities that provide both health and social care, using inspectors skilled in both areas. As well as ensuring inspectors will have the appropriate skill mix, it will also benefit providers, who will only have to be inspected by one body, compared with the current system under which they are inspected by both the health and local authority.

If we set up a separate regulator for private healthcare, there would be substantial difficulty for some providers being forced to cut in half the work they do across both health and social care. For example, mental health provision is often provided across the range of care needs. Our overall approach to breaking down barriers between health and social care is encouraging providers to develop innovative and flexible mixes of provision. This would be seriously undermined if we asked providers to register separately their different provision with two different national regulatory bodies.

I hope that I have convinced the noble Lord that although he does not necessarily agree with how we have dealt with the private healthcare sector, there is every reason to include the private healthcare sector within the provisions of this Bill and encompassed within the care standards commission. We shall be returning to this issue later in debate and specifically to the various aspects of private healthcare regulation. But I hope, having heard the arguments, that the noble Lord will now agree that the clause should stand part of the Bill.

Lord Laming

I regret to say that I am wholly unconvinced. I will say that again: I am wholly unconvinced by anything which the Minister has said. That is a first.

I find myself in a difficult position because I feel very strongly about Clause 2. As we go through the many amendments relating to Clause 2, I shall feel inclined to say: "Had you supported me in removing Clause 2, there would be no need to discuss this matter".

In the light of this discussion and what the Minister has said, and the fact that we will have opportunity to return to the matter, wise counsel suggests that should withdraw my opposition to the Motion. But I must say that I do so with an extremely heavy heart.

Clause 2 agreed to.

Lord Burlison

My Lords, I beg to move that the House do now resume.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.

Lord Burlison

My Lords, before we move to the Statement on influenza, I take this opportunity to remind the House that the Companion indicates that discussion on a Statement should be confined to brief comments and questions of clarification. Noble Lords who speak at length do so at the expense of other noble Lords.

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