In this first annual accountability hearing with Monitor, the Health Committee welcomes the strengthened role given to the hospital regulator in the approval and regulation of Foundation Trusts. The Committee strongly supports the view that the standards for authorizing Foundation Trusts must not fall as a result of the Government's desire to see all remaining NHS Trusts become Foundation Trusts. It welcomes the extension of Monitor's oversight powers for Foundation Trusts to 2016; that the powers will then be reviewed; and the fact that Monitor's new role, as set out in the Health and Social Care Bill, has been more clearly defined. The Committee believes Monitor has established a reputation as an effective regulator of Foundation Trusts and that it is important to safeguard that hard-won reputation. That means insisting on the maintenance of a rigorous approvals system. It also means maintaining an effective oversight regime in what are likely to be increasingly challenging times. Finally, following government amendments to the Health and Social Care Bill which were tabled at Commons Report Stage, it means the operation of an effective distress and failure regime for Foundation Trusts.

Responses to HC 1428, on the Annual accountability hearings with the Nursing and Midwifery Council (ISBN 9780215560933); 1429 on the Annual accountability hearings with the General Medical Council (ISBN 9780215560926) & 1430 on the Annual accountability hearings with the Care Quality Commission (ISBN 9780215561305)

Following its annual review of the work of the Care Quality Commission (CQC), the Health Committee reports that the bias of the work in the CQC away from its core function of inspection and towards the essentially administrative task of registration, represents a significant distortion of priorities. The Committee reports that: the CQC was established without sufficiently clear and realistic definition of its priorities and objectives; the timescales and resource implications of the functions of the CQC were not properly analysed; the registration process itself was not properly tested and proven before it was rolled out; the CQC failed to draw the implications of these failures adequately to the attention of ministers, Parliament and the public. Consequently, the Committee welcomes the government's decision to postpone registration of GP practices, and recommends that proper planning, including piloting of the model for registration, should be undertaken before the revised date of April 2013 is confirmed. The Committee also welcomes recent announcements that the CQC intends to undertake annual visits of all NHS and social care providers. It goes on to stress the importance of the role of inspectors in assessing the culture in care providers, especially concerning the obligation which rests on all healthcare professionals to raise concerns if they recognise, or ought to have recognised, evidence of failure of professional standards. Each provider organisation should recognise and respect this professional obligation and provide proper security to those professional staff who discharge it effectively.

This is the second annual accountability hearing with Monitor from the Health Committee. The parallel roles of Monitor and CQC were criticised in the Francis report on the Mid Staffordshire Foundation Trust (HC 898, session 2012-13, ISBN 9780102981469) because they created significant opportunities for confusion. The Health Committee concurs and stresses that it needs to be addressed urgently to avoid the twin dangers of gaps in regulation and duplication of regulation. This report concludes that the proposal to use a combination of transitional powers and licensing provisions (designed to apply to all providers of NHS care) to provide the framework for the long-term regulation of Foundation Trusts is profoundly unsatisfactory. The role of Monitor in relation to competition in the NHS remains unclear, and the respective roles of Monitor and the Competition Commission in the market for health and care services need urgent clarification. Monitor's positive approach towards the commissioning of integrated care pathways is welcome. Monitor should use its role in setting the tariff paid for certain NHS services (alongside the NHS Commissioning Board) to encourage system redesign and the integration of service provision, as well as to discourage "cherry-picking" of the most economically attractive patients. The establishment of a provider failure regime is welcome, but a number of important elements in that regime are not yet fully developed and further progress is needed over the coming months.

This year's inquiry into the work of Monitor concludes that the model of care provided by the health and care system is not changing quickly enough with the result that pressures continue to build, threatening the financial stability of individual providers, and therefore the quality of care provided The pressures are likely to be particularly marked in the acute sector as plans are prepared and implemented to achieve the resource transfer required by the introduction of the Better Care Fund from April 2015. Continuing this theme, the Committee argues that as the NHS financial situation tightens, the challenge for Monitor in supporting trusts in financial difficulty is likely to increase. The MPs emphasise the importance of addressing pressures within individual providers in the context of the local health economy. The requirement for major change in the care model can only be delivered if individual providers, and Monitor as their regulator, look beyond preserving existing structures and address the need to develop different structures to meet changing needs. The Committee also expresses concern that Monitor has not done enough to reform the system of tariff payments for providers, arguing that the current tariff arrangements often create perverse incentives for providers and inhibit necessary service change. It recommends that Monitor and NHS England should initiate a formal joint process for a prioritised review of the NHS tariff arrangements with the objective of identifying and eliminating perverse incentives and introducing new tariff structures which incentivise necessary service change

The Health Committee reports on the annual accountability hearings with the General Medical Council (GMC) (HC 1429) and Nursing and Midwifery Council (NMC) (HC 1428). The reports call for doctors and nurses to develop a wider responsibility for the overall quality of care delivered to patients and they have an obligation as professionals to report to their professional body any concerns they have about the quality of care being delivered by their colleagues. The GMC and the NMC must give a strong lead in this area and ensure that failure to act on this responsibility is regarded as a serious breach of professional obligation. The Committee stresses that both regulators need to have effective revalidation processes in place so that they can periodically check on how doctors and nurses are performing. The Committee recognises that the NMC is making steady progress towards being an effective regulator but cautions that there remains substantial ground to cover before it can be considered fully effective: work around pro-active regulation (risk-based visits) must be expanded; guidance about the care of older people must be reinforced by an action plan to deliver improved outcomes in this group. Government and both regulators must speed up efforts to resolve the serious problems posed by doctors and nurses who qualify elsewhere in Europe, and earn the right to work in the UK without having their language or medical skills tested. The UK and European law that underpins the workings of both regulators needs a complete overhaul.

The NHS needs to be an organization in which an open dialogue about care quality is part of the natural culture of the organization, not a duty which only arises in cases of service failure. Robert Francis made 290 recommendations in his report, but in truth they boil down to just one - that the culture of 'doing the system's business' is pervasive in parts of the NHS and has to change. Many who raise their concerns in the NHS at present risk serious consequences for their employment and professional status. But disciplinary procedures, professional conduct hearings and employment tribunals are not the proper place for honestly-held concerns about patient safety and care quality to be aired constructively. The NHS standard contract imposes a duty of candour on all NHS providers. This is an essential principle, but it is not adequately understood or applied. It should mean that all providers create a culture which is routinely open both with their patients and their commissioners. The same principle should apply to commissioners so that they are routinely open and accountable to local communities. The Health Committee recommended this approach in 2011 and repeats that now. It should be a prime role of the CQC to encourage the development of this culture within care providers, and of NHS England to develop the same culture within commissioners. The Health Committee will in future work closely with the Professional Standards Authority to develop the accountability process for professional regulators in healthcare