Clause 89 - Reviews and performance assessments

Care Bill [Lords] – in a Public Bill Committee am 2:00 pm ar 28 Ionawr 2014.

Danfonwch hysbysiad imi am ddadleuon fel hyn

Photo of Paul Burstow Paul Burstow Democratiaid Rhyddfrydol, Sutton and Cheam 2:00, 28 Ionawr 2014

I beg to move amendment 52, in clause 89, page 80, line 23, at end add—

‘in particular indicators relating to specified relevant physical and mental health conditions’.

Photo of Andrew Rosindell Andrew Rosindell Ceidwadwyr, Romford

With this it will be convenient to discuss the following:

Amendment 152, in clause 89, page 80, line 30, at end insert—

‘(c) including specific reference to the method it will use to evaluate performance in respect of safeguarding issues, including protection from financial abuse.’.

Amendment 155, in clause 89, page 80, line 30, at end insert—

‘(c) explaining the reasons for choosing the method described under paragraph (b).’.

Amendment 143, in clause 89, page 80, line 31, leave out ‘may’ and insert ‘must’.

Amendment 144, in clause 89, page 80, line 38, at end insert—

‘(a) performance indicators for individual services provided by service providers,’.

Amendment 156, in clause 89, page 80, line 38, at end insert—

‘(c) guidance to service providers on how information collected under this section should be made available to the public.’.

Amendment 159, in clause 89, page 80, line 41, at end insert—

‘(aa) must consult relevant organisations including—

(i) professional bodies;

(ii) royal colleges;

(iii) trade unions;

(iv) commissioners;

(v) patients’ groups; and

Amendment 158, in clause 89, page 80, line 42, at end insert—

‘(7A) In respect to subsection (7), the Secretary of State must—

(a) publish the minutes of the consultation with the Commission, and

(b) make a statement to Parliament on the consultation with the Commission.’.

Photo of Paul Burstow Paul Burstow Democratiaid Rhyddfrydol, Sutton and Cheam

Thank you, Mr Rosindell, for the announcement about the small change to the groupings. It will help the presentation of the amendments I will speak to later, so I am grateful.

With amendment 52, I intend to explore the Government’s thinking about how inspection might evolve to reflect better the fact that people experience their care not in single institutions but in care pathways. I will also explore how we might ensure that the Government’s intentions for integration, which are evident in the Bill, and the changes made in earlier legislation they took through, are reinforced by the inspection system. I would like to tease out those things.

The inspection regime that the Bill develops remains institutionally focused, rather than focused on patient pathways and specific conditions. That could give rise to a situation where a poor rating for an institution that was not performing well could mask high-performing services or pathways within it. Patients could be deterred from being treated there, even though they would be treated through an excellent patient pathway, and, as a result, they would not get the outcomes they wanted. The purpose of the amendment is to encourage the Government to give further thought to how we ensure that the inspection regime is focused on patient pathways and conditions, rather than institutions. Such a focus will help to facilitate choice and service improvement in the way the Government originally intended and in a way that aligns with the recommendations in the original Nuffield Trust review that led to the development of the policy around which this part of the Bill is based.

In the Nuffield Trust report for the Government, “Rating providers for quality: a policy worth pursuing?”, it said:

“the goal should be to introduce ratings that drill down to the level of individual departments and clinical services so that patients can have a much truer understanding of the quality of care provided in those departments.”

Prostate cancer is the most common cancer among men. We know from the latest cancer patient experience survey that there is significant variation in the quality of services. For example, more than a quarter of patients reported that they did not fully understand the side effects of their treatment. When one considers that the side effects can be lifelong and deeply embarrassing—incontinence and erectile dysfunction, to name but two—and that more than three quarters reported that they were not told about the possibility of being involved in clinical trials, we begin to understand that examining the care pathway for prostate cancer is important. The outcomes that matter for patients are not just surviving the operation, but how they can lead their lives afterwards. Understanding that and inspecting for it, as part of the way the CQC works, would be helpful.

Another risk is that the inspection serves to preserve inefficient, antiquated or outdated models of service delivery, which is an area in which the Government want, through the better care fund, to see transformation. Clinically led commissioning is clearly resulting in the use of different models to improve models of care, such as prime contractor models and outcomes-based contracting, which can facilitate integration. For example, an acute trust might take on responsibility for not just providing acute prostate cancer services but organising community prostate cancer services. However, an institutionally focused model of inspection could lead  to a hospital being rated highly for the prostate cancer services it provides, even if the services that are organised outside the hospital are of poor quality and result in poor outcomes. This is a particular issue for prostate cancer. Again, some interesting results from the cancer patient experience survey show that there is a really significant variation when it comes to people’s experience of integrated services. Indeed, the proportion of prostate cancer patients reporting that they experienced integrated cancer services range from 48.1% at Imperial College Healthcare NHS Trust to 93.1% at Frimley Park Hospital Foundation Trust.

For me, this is about measuring outcomes that matter to patients and using an inspection regime to drive that. So a regime focused on institutions may lead to improvement in the care offered to patients in active treatment, but not in the care offered to patients who benefit from such treatment but have chosen not to receive it. An example of this might be a patient with hepatitis C. For years, the lengthy treatments for hepatitis C, which can cause really miserable, flu-like symptoms, have discouraged thousands of patients from being treated, even though they could be cured. Public Health England estimates that just 3% of chronic hepatitis C infections are treated every year. The inspection regime could support the aims of the Government to develop high- quality services which transcend organisational boundaries, something that I know the Minister is very passionate about in taking the agenda of integration forward. I hope that he can offer some reassurances in two ways: first, by confirming that condition-specific measures are on the CQC’s agenda; and secondly, by taking steps to ensure that the issues I have spoken about with reference to prostate cancer and hepatitis C are being examined by the Care Quality Commission.

Photo of Jamie Reed Jamie Reed Shadow Minister (Health)

I thank the right hon. Member for Sutton and Cheam for moving his amendment and starting what is an extremely important part of our discussion on the Bill. I have huge sympathy with everything he has just described. This is not really the place to talk about individual ailments and complaints, but I am a type 1 diabetic. Diabetes is, I think, responsible for 26,000 deaths per year in the UK. Everybody diagnosed with type 1 or type 2 diabetes is meant to receive nine key tests every year. It does not happen—I have yet to find anyone with either type who gets those nine key tests. When one looks at the information provided by diabetic-concerned charities and others, nowhere in the country has complete coverage of diabetic patients within their catchment areas who receive those nine key tests. My special pleading is over.

Like the previous discussion, this group has a number of amendments, but it is right that we look at the purpose of clause 89 and its intended aims before moving on to the individual amendments. I am sure that nobody will be surprised to hear that the Opposition support the principle of ensuring that high quality is maintained throughout every service available to patients, and also of providing patients with more information, in greater detail, about their local services and giving them greater access to the state of the art with regard to the information in the wider health economy. These are laudable aims, and I am glad that the Government are committed to them. Yet, as with so many other parts of the Bill, the legislative application of these principles may not yet be up to the mark.

The new powers in proposed new section 46 will allow the Secretary of State to prescribe particular types of services or providers in relation to whom the CQC should publish performance information, so as to enable the public to make informed choices about the quality of services being provided. As I mentioned previously, this is a principle that we must all welcome, but I fear that if only one indicator is published this would mask the true performance of the service. That is a fear on which I will expand soon. Performance ratings could be an effective tool for giving more information to patients and the wider public, but the application, as has been suggested, would have the inverse impact, with a single score hiding more information than it would show. That is in nobody’s interest.

First, as the service provider is the one being assessed, as stated in clause 89(2), it suggests that the overall rating will not have sufficient detail to assess individual services. Where a service provider is providing one service, it may be an adequate reflection of what is happening on the ground, but for a hospital trust, where the services are wide-ranging, one aggregate score on the performance of the service provider could do more harm than good. I am sure we all hear from constituents of their experiences of hospital. I am frequently told that intensive care in our local hospital is excellent, but in some cases people get moved out into an unmade bed with a half-drunk glass of water on the bedside table. That is a colloquial way to explain the difficulties of having a single indicator as a guide to the quality of an institution.

The right approach would be to publish more information and to broaden the final conclusions on performance to show a number of factors. Single performance ratings for a restaurant or a hotel may be accurate enough in determining performance, but it is simply too blunt a tool accurately to demonstrate the performance of a health provider offering multiple services containing complex, sophisticated systems. We do not want a system akin to TripAdvisor, though even TripAdvisor uses four separate indicators to rate restaurants—so I am told. Other websites are available.

It is down to the Care Quality Commission to determine its methodology for inspecting and reviewing hospitals. I would be grateful if the Minister could explain how the Government intend to ensure that sufficient detail is published. Will that be through guidance? I believe that the matter is critically important.

Amendment 156 would require the CQC to issue guidance to service providers on how any information collected under this section should be made available to the public to ensure that some uniformity is maintained from service provider to service provider. That would enable the public to compare and contrast performance data for different providers, and would ensure that the public could make more informed choices on a like-for-like basis.

Given the qualified support I have outlined for the principle behind this idea, but the reasoning for criticising the overall application of the principle, I will now discuss each amendment in turn. The right hon. Member for Sutton and Cheam started the debate with amendment 52, which would ensure that the CQC judged different services by different indicators. It is similar in that regard to amendment 143, on which I will expand later.

Amendment 152 is to ensure that the CQC can do and does do everything it can to spot and highlight instances of financial abuse, whether in residential homes or people’s own homes, which, as we have consistently argued, is the key challenge in this sector. Our amendment would place a duty on the CQC to ensure that, when it prepares a statement setting out how often the CQC will undertake reviews and the methods it proposes to evaluate performance, it must include specific reference to how it will evaluate performance on safeguarding, including protection from financial abuse.

Research in 2007, funded jointly by the Department of Health and by Comic Relief, suggested that in that year 57,000 people aged over 66 had experienced financial abuse. That makes it the second most common type of abuse after neglect. That view is supported by research from Action on Elder Abuse, which says that around 20% of calls to its helpline are about financial abuse. Surveys also show that most financial abuse takes place in people’s own homes, with abuse in residential care accounting for a fifth of cases. For the fourth fifths of cases that relate to abuse in a person’s own home, 70% of the financial abuse is by a family member and 30% by a care worker. We need a system that prevents both; we need to ensure that both residential and domiciliary care providers have proper processes in place to identify, prevent and tackle financial abuse, but also to train care workers to spot signs of financial abuse from family members.

Regulation 11 of the Health and Social Care Act 2008 gave the CQC clear powers to ensure registered providers take reasonable steps to identify financial abuse, prevent it before it occurs and respond appropriately to any allegation. I do not pretend for a second that that is easy. It is an incredibly complex issue, and I entirely understand that some families may well respond negatively.

Providers must be able to show that they keep individual records of all income received, money spent and any valuables held; that money and valuables are not used by the service for the running or management of the service; that people who use the services can access their money and valuables in a timely way; and that the manager also becomes the agent of people who use services only where there is no suitable person outside the service available to undertake that role.

The CQC inspectors can check for irregularities, but we understand that checks are not undertaken as a matter of course. Will the Minister provide some clarification on that by explaining how irregularities become apparent to the CQC if it does not perform checks on a regular basis? That is an important detail that we need to get right.

The consultation document recently issued by the CQC, “A fresh start for the regulation and inspection of social care” asks about the commission’s new methodology for inspecting standards in social care, but says nothing about financial abuse. Indeed, there is a section on “Promoting a culture of quality, safety and openness”, but the word “abuse” is absent from that document. Will the Minister talk to the chief inspector of social care about that and ensure that this issue is considered in greater detail? To me, this seems like a missed opportunity—one that we cannot afford to miss.

Amendment 155 is on the methodology that the Care Quality Commission will employ to determine performance levels. It would amend subsection (4) of proposed new section 46. The subsection lists what the CQC must include in its statement: namely that it must publish the frequency of the reviews and set out the methodology it intends to use. The amendment would require the CQC to justify its choice of methodology, which would give more weight to the conclusions that it draws.

Amendments 158 and 159 relate to the consultation process that the CQC must adhere to before publishing its statement on the methodology, as required by subsection (6). As the Bill stands, the Secretary of State must be consulted by the CQC, so to maintain its independence as laid down by clause 88, we tabled an amendment that would require details of that part of the consultation to be published. Much like in the appointment of the trust special administrator, which we discussed earlier, the Secretary of State will have the ear of the CQC in this regard, so we feel it is right and proper that the Secretary of State relays details of the consultation to Parliament by an oral statement, supplemented by a written statement, with opportunities for colleagues to supervise the process.

In line with the principle behind amendment 128, which was tabled by my hon. Friend the Member for South Shields and discussed in the previous debate, we believe that the list of statutory consultees should be extended to include those listed in amendment 159. Proper consultation with wider industry groups would create a system with buy-in from all major stakeholders, thus ensuring much more effective partnerships and trust in the process. A trusted process is likely to stand a better chance of success.

Whether through warning notices under clause 81 or reviews in this part of the Bill, our purpose is to improve care standards. It serves no one simply to point out bad practice and then walk away. It is right that the CQC works with providers to improve care, but it is only through communication, consultation and co-operation at every stage that the necessary relationships can grow. This is iterative, intelligent regulation.

Amendment 143 was tabled to press the Government on the methodology that the commission might use. Subsection (5) is not well written. Will the Minister explain what

“different indicators for different cases” means in the application of this proposed new section? I am reluctant to offer a blank cheque for that. Does it mean that two accident and emergency departments, or two maternity wards, or two intensive care units may be judged differently? If every service provider is judged against different indicators and benchmarks, how will that promote greater information for the public? It would be impossible to compare and contrast the various strands of information realised with such an approach. It would also make the establishment of universal standards almost impossible.

If, however, the meaning is that different indicators may be used when judging the performance of an A and E department and when judging a maternity ward, we would argue that that does not go far enough. It is essential that different services are judged differently to ensure an accurate description of the service offered. That goes to the heart of understanding risk: a topic  that is almost impossible for anyone to communicate, let alone politicians, but I firmly believe that the public understand risk better than we give them credit for.

Amendment 144 was tabled with the intention of ameliorating the main concern that I outlined at the beginning of my remarks: one performance indicator for a service provider cannot provide an accurate representation of the performance of the individual services. It would put a requirement on the Care Quality Commission to publish all performance indicators for each individual service. One indicator, much like a mean average, can be skewed substantially by services operating at either extreme of that performance scale. That is to say, an extremely poor service can hide a good-quality care service provided elsewhere by the same provider, and an extremely good service could mask poor performing care.

I can put it no better than this. In his superb report on hospital mortality rates last year, which I cite again, Sir Bruce Keogh stated that:

“We found pockets of excellent practice in all 14 of the trusts reviewed”.

These trusts were selected for inspection on the basis of one performance indicator, namely mortality rates, but this does not on its own show the full and accurate picture of care in the hospitals reviewed. The fact that in every hospital trust investigated by Sir Bruce Keogh mortality data showed a drop of between 30% and 50% over the previous decade also proves the point.

In his response, I hope that the Minister will go into some detail about how he expects these indicators to work in practice. We must be precise. We want to give patients and public a right to an informed choice, but we need to be entirely accurate and fair. Poor hospitals should not be allowed to masquerade as adequate, and good ones should not be damned by faint praise. As we said in debate on the previous clause, the often cited comparison with Ofsted and failing schools is not accurate or appropriate. Accuracy is key here and this is a point to which we will return.

Photo of Norman Lamb Norman Lamb The Minister of State, Department of Health 2:15, 28 Ionawr 2014

May I first pick up on a theme raised by my right hon. Friend the Member for Sutton and Cheam about the importance of looking at pathways and seeking to develop more integrated working, sometimes bringing different institutions together, rather than taking an obsessive look at the individual institution? I can tell him that the power exists to carry out thematic reviews under section 46 of the 2008 Act. The current intention is to use the special review under section 48 of that Act, rather than the performance assessment in section 46.

The CQC will be able to carry out such a review without seeking ministerial approval, as it is about service provision and the power in section 48 is very flexible. My right hon. Friend rightly expressed the concern that an obsessive focus on the institution rather than on the whole integrated package of care must not be allowed to frustrate institutions locally, shifting their approach to join up care in the interests of the patient. We must ensure that this does not happen. The provisions that I have referred to and the power in regulations allow us in time to adapt and ensure that we can focus on pathways of care through this regulatory process. However, my right hon. Friend raises an extremely important point.

I will pursue this issue further in my discussions with the Care Quality Commission, because it is really important that everyone, including the regulators and other arm’s length bodies, focuses on facilitating joined-up integrated working, rather than putting blockages in the way.

Photo of Paul Burstow Paul Burstow Democratiaid Rhyddfrydol, Sutton and Cheam

I wish the Minister well with those discussions, but as part of them, will he give some thought to the fact that using the thematic inspection route, rather than having a performance element to it—which is what we are debating at the moment—may mean that what gets measured will get done? Measuring on an institutional basis is the old world. We need to start preparing the ground for the new world, in which we measure performance from a patient perspective and that is pathways. Even if we cannot do that for everything to start with, some experiments could be incredibly helpful. Is that an issue that we can discuss?

Photo of Norman Lamb Norman Lamb The Minister of State, Department of Health

That is a very attractive proposition and I will be sure to include it in my discussions. I have a meeting with the chairman coming up and I know that he is completely committed to the principle of integrated joined-up working, so he will be a receptive audience.

The shadow Minister also raised concerns about the potential risk of single rating. That was looked at by the Nuffield Trust in its work. The way that we are seeking to do this should allay his fears. On the complexity of the rating, the CQC says that it will

“produce ratings and the information on which the ratings are based at a level which recognises the complexity of NHS services and is useful to people who use services as well as those who provide and commission NHS care”.

The CQC is to provide ratings for certain individual services, for example emergency or maternity services, as well as for the hospital as a whole. The CQC would also like to provide ratings for each of the key questions: is the service safe, effective, caring, responsive to people’s needs and well led? There will be a much richer picture provided of the performance of a hospital, rather than a single rating for the whole institution.

I am aware that sometimes when a hospital is damned by a single rating and that is all anyone hears, many people doing brilliant work in that hospital will be massively demoralised by the sense that that is the only thing that counts and that they are all damned by that one rating. The idea that there could be a fuller picture provided is incredibly helpful in reassuring the staff, quite apart from the patients who use the service, that it is a rich picture. There may be particular failings that are critical for the organisation to address, but pockets of brilliant activity should also be recognised.

Photo of Jamie Reed Jamie Reed Shadow Minister (Health)

The Minister is making a really important point, and I appreciate every word of his response. To build on it a little further, can he say with certainty that we will not have broad categories, definitions and ratings of hospitals as good, bad or failing? That is the kind of categorisation we have with the Ofsted regime and it does not help. He has almost confirmed that; I am seeking further clarity. Secondly, has any consideration been given to the ratings regime with regard to recruitment at certain trusts? The last thing we want to see is for institutions to be labelled failing and for that to destroy any prospect of those trusts undertaking the necessary recruitment to improve services.

Photo of Norman Lamb Norman Lamb The Minister of State, Department of Health

It is a balance. We must equally ensure that we do not hide failings from the public. The public as users of NHS services need to know what their local services are like. They need to be able to exercise that choice that the hon. Gentleman’s Government rightly introduced. They can only do that if they have a full understanding of the quality of the service. I repeat that, if there is more than the single rating, with an understanding of performance against all five criteria, and how particular departments such as A and E and maternity are performing, we will have a much fuller picture to give the public the information they need in order to make a proper judgment.

Photo of Bill Esterson Bill Esterson Llafur, Sefton Central 2:30, 28 Ionawr 2014

I only missed four minutes, though I am sure they were very important ones. My hon. Friend the Member for Copeland mentioned Ofsted and the Education Committee took evidence from the head of Ofsted, Sir Michael Wilshaw, last week. We discussed some of the points my hon. Friend has just made. Sir Michael said that he saw the future for Ofsted not just in regulation but in supporting those it inspects. Does the Minister think the role of inspectors is to look at improvement and support as well? Does he see that as part of the regime he is looking at, in the way that Sir Michael set out in relation to education and children’s social care?

Photo of Norman Lamb Norman Lamb The Minister of State, Department of Health

We will, as we go through these provisions, demonstrate the system that we seek to apply in the health and care system. There is some real merit in the Care Quality Commission’s being seen as the nation’s whistleblower. It has the ability to identify failings and not get caught up in the difficult task of how one seeks to improve that service. If it is free just to make its clear and independent view of the quality of a service, and, if necessary, Monitor or the Trust Development Authority will undertake the work to improve that service, that is a rational approach to achieving the improvements we are after. The rating system we are introducing, particularly given that it has more granularity than a single rating, as we have just been debating, creates an incentive for improvement.

Things happen with legislation, but ultimately just having a regulator, which determines whether an organisation meets minimum standards creates no incentive for improvement. If an organisation is rated as “good”, it will want to achieve “excellent”; that is human nature. The system has been designed, with the brilliant help of Jennifer Dixon and Nuffield, to ensure that the inspections and the basis upon which a rating is achieved are robust and thorough. It is not tick-box, but based on clinicians’ judgments, the views of staff who are interviewed when the inspection takes place and the views of users of the service. That creates a dynamic incentive to improve. It has potential power to achieve real improvements for the users of these services.

The amendments that we are now considering relate to the new system for the performance assessment of providers to be operated by the Care Quality Commission and its ability to operate with greater autonomy as the  independent regulator. The Bill introduces a new system of regular assessments of registered providers which has no requirement for ministerial approval of the methodology. Ministers will be consulted over the methodology, but will not be able to set or agree the method of ratings or specify what medical conditions should be included in the indicators the CQC devises. That is in the spirit of independence.

That is in line with a wider package of measures designed to give the Care Quality Commission greater operational independence, such as the removal of the Secretary of State’s powers to intervene in the day-to-day operation of the CQC and placing a duty on the chief inspectors to operate in a way that ensures the independence of the CQC’s judgments. Why is this important? The independence of the CQC from the Government is central to its credibility as an authoritative source of information about the quality and safety of health and adult social care providers.

The system of performance assessment of registered providers that CQC is developing will be central to providing the public with fuller and more reliable information about the quality of care provided by their local hospitals, GP practices and care homes. This system has to be developed by the CQC, and it has to be responsible for its development. We will not achieve this by placing numerous additional requirements on the CQC in developing the methodology, as this series of amendments seeks to do. Let me try to explain why.

The CQC may consider certain indicators to be relevant to and apply equally across both health and adult social care sectors and to different types of services. Amendment 143 would prevent the CQC from adopting the same methodology where appropriate. Equally, the CQC may conclude that different sectors require different indicators. Consultation with stakeholders, including the Secretary of State, will inform the CQC’s approach. Once they are devised, the CQC would be required under clause 89 to publish its quality indicators. Amendment 144 is therefore unnecessary.

Amendment 52, which my right hon. Friend the Member for Sutton and Cheam tabled, makes a specific reference to mental health services. I should like to reassure him that the CQC’s ratings system will look at that area. Providers of mental health services are registered with the CQC and will receive a rating. The CQC has recently appointed Paul Lelliott as a new deputy chief inspector with expertise in mental health. I met Paul last week and I am confident that the CQC will really focus on mental health.

Amendment 152 would similarly place a specific requirement on the CQC to consider safeguarding issues and financial abuse in rating providers. I am self-evidently a strong advocate of the need to protect vulnerable people from the risk of abuse. Safeguarding against abuse, including financial abuse, is a key feature in the proposed fundamental standards for registration with the CQC, on which we are currently consulting.

We have, through the Bill, set out local authorities’ responsibility for adult safeguarding for the first time in primary legislation and we have specifically referenced financial abuse in clause 42 to make it completely clear that financial abuse should be considered as part of a safeguarding inquiry. I would hope that in rating providers, the CQC will consider how it protects patients and service users from the risk of abuse. However, this  decision has to be with the CQC and should not be a requirement in the Bill. The Bill places a requirement on the CQC to publish a statement setting out how often it will inspect providers and the method that it will use.

Amendment 155 would also require it to explain its reasoning for this method. I do not see the purpose of this amendment. The CQC will consult on its performance assessment methodology and set this out in the statement that it will be required to provide. These existing requirements will ensure that the ratings are developed in a collaborative and transparent way, and an additional requirement to explain the reasoning behind the methodology will add nothing to this.

Amendment 156 would require the CQC to issue guidance on how service providers should make information about the results of performance assessments available to the public. Clearly, the rating system will succeed only if the findings are readily available, including being made available by providers themselves. The CQC itself will be required to publish a report of each performance assessment.

There is a risk, of course, that providers which receive a critical rating might simply choose not to publicise this. I am not, however, convinced that guidance issued by the CQC would be effective in preventing this. A provider that was determined to hide a negative rating would not necessarily be persuaded by guidance to come out into the open and declare its inadequacy. Instead, I will ensure that as regulations are developed we consider the issue of a requirement for providers registered with the CQC to make available the results of a performance assessment carried out by the commission.

One interesting development is that any member of the public can go on to NHS Choices and find any provider registered with the CQC, find out what its rating is and a whole host of other information, potentially including TripAdvisor-style comments from users, family members and so forth. The more that this becomes the place to go to find out about the quality of a care provider, a domiciliary provider, a care home, a nursing home and so forth, the better. It will mean that no care provider can hide away unfortunate, embarrassing information. The CQC has provided a widget that enables a provider of care to provide a link directly from the provider’s website to the findings of the CQC inspection, but they are not required to do so. Could we require providers to have that link on their websites? These are things we are looking at, but I think ultimately—because I suspect I am addressing the concern that he raises—the hon. Member for Copeland will probably feel more comfortable with the idea of a requirement to publish rather than anything simply in guidelines. I hope I have reassured him in that regard.

Amendment 158 concerns the consultation that the CQC is required to carry out in developing its system of performance assessment. The Bill will require the CQC to consult the Secretary of State and allow it to consult any other bodies and people that it considers appropriate. The amendment would require the Secretary of State to publish minutes of any consultation with CQC and make a statement to Parliament about this consultation. I understand the reasoning behind the amendment, that it is designed to ensure that performance assessment  methodology is independent from Ministers. We are already taking major strides in the Bill to ensure the CQC’s independence.

Clause 88 removes nine separate powers of the Secretary of State to intervene in the commission’s day-to-day work and clause 87 requires chief inspectors to have regard to the independence of the CQC. In addition, the Bill removes a requirement for the CQC’s performance assessment methodology to be approved by the Secretary of State. The CQC will not be required to carry out a separate consultation with the Secretary of State, rather, it will carry out a consultation in which the Secretary of State will be one party, along with others, in that consultation process. The outcome of the consultation will be the performance system itself, and here the CQC will be required to publish both a statement setting out the methodology and method it will use and the indicators against which it will assess performance. Requiring the Secretary of State to publish the minutes of any discussions about ratings or to make a statement to Parliament will not enhance what we have designed to be an independent and, critically, a transparent system.

Amendment 159 would require the CQC to consult a number of specific bodies in developing the performance assessment system. I do not argue that any of the organisations mentioned in the amendment should not be consulted—it is clearly a sensible list—but specifying in the Bill which organisations have to be consulted would constrain the CQC’s ability to carry out the consultation in the way that it considers most appropriate as an independent body. Hon. Members will, of course, be aware that organisations and people that the CQC must consult can be set out in regulations, so while I am not minded to tie the commission’s hands in this respect, it is my view that if we were to do so, regulations would be a more flexible way of doing it than putting it in the Bill. I hope that that is helpful.

Photo of Jamie Reed Jamie Reed Shadow Minister (Health)

The Minister has engaged, typically, in real detail with the concerns that we have raised. There are two small outstanding areas of concern. Is it the intention that the information on the ratings of hospitals that the CQC makes available to the public will include how often, when, why and how warning notices have been issued to a particular trust? Has any regard been given in the Department—I touched on this earlier—to how this rating system will affect recruitment in challenged trusts? I completely appreciate that that is not the principal aim of the clause, but we do not want to see a spiral of decline in trusts, where we know we need to provide help and instead, we might see what we see in the education sector: good teachers refusing to go to schools which need good teachers.

Photo of Norman Lamb Norman Lamb The Minister of State, Department of Health

I can certainly confirm, on the latter point, that, as we have been discussing, in the whole framework of the CQC regime, and, indeed, the response to Francis more generally, we have absolutely focused on the importance of getting the balance right.

Indeed, that is one of the reasons why we chose not to apply the duty of candour to individuals, for example. If individuals in an organisation are faced with the potential for committing a criminal offence almost inadvertently, or there is a fear that this will be the case,  that potentially creates the very negative culture to which my hon. Friend the Member for Totnes, who is not here, referred in an earlier discussion. Getting the right balance between sanctions that can be applied and the attractiveness of the role and so forth is incredibly important, and we need to understand that.

This has been at the forefront of our minds, but overall we feel that a system with great openness and transparency about both the successes and failures of organisations, and which allows us to celebrate brilliant care, creates conditions which are more attractive to professionals. At the moment, beyond anecdote it is very hard to judge which are the great hospitals, where fantastic leadership does brilliant things. That will be very clear to everyone in this new system, and being able to celebrate those leaders in the NHS who are showing the way to others will be a real strength of that system. Risks are always involved, but there are also real potential gains in making the NHS a more rather than less attractive place to work. I hope I have answered that question.

On the earlier point, warning notices will be published and available on the CQC website. Essentially, this is a completely transparent process. We have sought to take an approach of openness and transparency, on the basis that if there is no hiding place for poor care it is less likely that there will be poor care. The openness of publishing the outcomes of inspections and the notices that have been served will again help drive up standards, which ultimately is what we all want to achieve.

Photo of Jamie Reed Jamie Reed Shadow Minister (Health) 2:45, 28 Ionawr 2014

I am grateful to the Minister, and I do not seek to divide the Committee.

Photo of Paul Burstow Paul Burstow Democratiaid Rhyddfrydol, Sutton and Cheam

Briefly, I thank the Minister for his response to the amendment in my name. The changes he outlined today, about the competency of the CQC to make its own decisions about its methodologies and so on, are incredibly welcome. As he was describing it, I was reminded of debates which took place when the previous Government established for the first time a national body to regulate social care. That argument was made then by some now Government Members, who were then in opposition. It is good to see that principle being established now, as it is really important.

I also thank the Minister for what he said on mental health. I did not particularly direct my remarks to this, but again it is an example of the need to look at performance ratings in a way which is not just about institutions. The experience of mental health services necessitates looking at the way in which acute hospital deals with people who attend an A and E department. This may well result in their having a particularly bad outcome and a bad experience, and we also need to look at the way in which long-term conditions—physical and mental—are dealt with together.

I am really grateful that the Minister will raise some of these issues when he next meets with David Prior. Hopefully we will hear the outcome, and with that, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendment made: 154, in clause 89, page 80, line 29, leave out ‘or local authority’.—(Dr Poulter.)

Clause 89, as amended, ordered to stand part of the Bill.