Care Bill [HL]
Baroness Emerton Excerpts(10 years, 10 months ago)
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Baroness Emerton
Baroness Emerton
My Lords, in moving this amendment I shall also speak to Amendment 86PA.
Clause 5 emphasises quality, which is to be welcomed, and places promoting diversity and quality in the provision of services in the Bill. However, on behalf of nurses, the Royal College of Nursing thinks that it is not enough merely to quote “quality”. Local authorities are responsible for commissioning services from providers and have a duty to ensure that these providers and services are effective to meet the needs of the individual. It does not believe that at the moment local authorities are fulfilling these duties and responsibilities if they commission providers who fail to deliver high-quality care and, worse, provide care that detrimentally impacts on the health and well-being of individuals, as has been demonstrated in some recent high-profile cases.
As commissioners, local authorities must be part of a system-wide approach to safeguarding vulnerable groups. They are therefore falling negligent in their role if they commission providers and services that are not sustainable and fail both financially and clinically.
The potential impact of this was demonstrated recently with Southern Cross, where the health and well-being—and, indeed, lives—of care home residents were put at risk following the failure of its business model. For this reason, I believe that local authorities have a responsibility for ensuring that services that are commissioned by them are of high quality and sustainable. The two amendments are to that effect. Amendment 86HA seeks to insert the word “sustainable” and Amendment 86PA seeks to insert the words,
“the importance of ensuring the sustainability and high quality of the providers it commissions”.
I beg to move.
Lord Hunt of Kings Heath
My Lords, as this is my first intervention, I refer noble Lords to my interests as president elect of GSI, chair of an NHS foundation trust and a consultant and trainer with Cumberlege Connections.
I have three amendments in this group. Amendment 86J seeks to delete “high quality services” and instead insert,
““services appropriate to their needs as identified in the needs assessment and carer’s assessment”.
The problem with the draft as it currently stands is that it is very vague and entirely subjective depending on who is defining “high quality services”. Perhaps the noble Earl can clarify how the Government think it ought to be defined. Otherwise, there is a risk of uncertainty and inconsistency which, certainly when it comes to eligibility criteria, the Bill is designed to eradicate.
My second Amendment 86K would ensure that those in receipt of care and those involved in providing care are involved in shaping the market, as required under Clause 5. I have received a number of submissions about the market-making role of local authorities, and I was concerned to receive a submission from the Association of Directors of Adult Social Services, which said that while the intention of Clause 5 in promoting quality and diversity within the market is laudable, ADASS was of the view that the proposed duty placed on local authorities is wholly unrealistic. It points to a large number of providers that have no relationship or contact with local authorities, and says that combined with increased personalisation and limited leverage through the regulation framework, the ability of local authorities alone to influence diversity and quality of service is restricted.
I was very disappointed with that response, and rather taken aback by it. I hope that the noble Earl will share my view that in fact local authorities ought to be able to influence not only the market but the quality of care provided by private providers to a very great extent. Would the Minister accept that, to be effective, local authorities need to have a strong engagement both with users of services and carers, and with those who are providing services, too? That is why I tabled the amendment.
I listened with great interest to the noble Baroness, Lady Emerton, and I very much agree with her about the need to ensure quality in provision of service. That brings me to my own substantive Amendment 86P, which is very much concerned with the conditions under which care workers are employed in the main by the private sector. This is a hugely important issue. Clearly, we have a growing number of disabled and older people who need care and support. The people working in the care sector are vital. We need quality people who are highly trained and who can give the right commitment to the vulnerable people they are asked to care for. Clause 5 is important because what we see is a very fragmented industry delivering care that in many cases is of questionable quality and employing insecure, low paid, unregulated staff. Amendment 86P is concerned with the importance of fostering a sustainable workforce to encourage the acquisition of skills and decent working conditions that support the continuity and quality of care.
I was shocked to see a parliamentary Answer from the Minister’s honourable friend Mr Lamb recently, showing that more than 300,000 people working in the care sector are employed on zero-hours contracts. The point that I wish to make is this: how can people who do not have the security of knowing what they will earn pass on a sense of security to the people whom they care for? The rise in zero-hours contracts is bad for service users, many of whom are, of course, extremely vulnerable. There is another issue. People who are being cared for want to see the same person to have a continuity of care relationship. We know that that is severely hindered by those wretched zero-hours contracts. I believe that secure employment would allow staff to concentrate on caring rather than worrying about whether they are earning enough money for themselves and their families to live on.
I ought to declare an interest as a member of UNISON, which produced an excellent report, Time to Care, which undertook a survey in 2012 of care home workers. It showed that 80% of those who responded had to rush work or leave a client early to go to another call on what is called call cramming— in other words, too many calls for a care worker to undertake—and 56% received between the national minimum wage and £8 an hour. The majority did not receive set wages. Not surprisingly, turnover is high, while wages and conditions are poor.
Here is a shocking statistic. Nearly 57.8% are not paid for travelling time between visits. This morning I met a carer in Southwark who works roughly 20 hours on a zero-hours contract. She reckons that, because of the travelling time, she actually works for 27 hours, but is paid for only 20. The problem is that there is a race to the bottom because local authorities are, in my view, neglecting their responsibilities for ensuring that, when they place contracts, they are with good quality organisations. The companies who are exploiting their workers in this way are winning contracts at the expense of companies who treat their employees wisely. No wonder, therefore, that 36.7% of respondents are often allocated different clients on a daily basis, so that there is no chance of any relationship being developed.
There are many other statistics. The scandal of the 15-minute visit is well known. Indeed, the UK Homecare Association survey shows that three-quarters of all trips to old people have to be completed in less than half an hour and one in 10 is limited to no more than 15 minutes.
In Committee last week, I discussed with the Minister whether the CQC could be persuaded—or indeed, I hope, instructed—by your Lordships, to prioritise the regulation and inspection of local authorities in their commissioning duties. We have heard a lot about the CQC’s past failures and future hopes. It is clear that the focus is going to be on the NHS. I do not disagree with that, but when you think of the thousands of vulnerable people dependent on care workers, I wonder if the priority is right. If I were in the CQC’s shoes, I would focus on the care sector and particularly on local authorities and their own responsibilities. That is probably the best way to get into this issue.
We could have a debate about the regulation of social care workers. We could debate mandatory training and the noble Baroness, Lady Emerton, has tabled an amendment which would very much focus on that. I hope the Minister will recognise that we have a problem here. If we are to see this legislation enacted in the way that we all hope it will be, I am convinced that we have to look at the way that workers in the care sector are employed and do everything we can to prevent the abuse that we are seeing with these zero-hours contracts.
Baroness Emerton
My Lords, I thank noble Lords who have contributed to this debate, which has been extremely wide and meaningful when, as the Minister said, it is the first time that legislation has tackled the issue of going to the market place for care. Enough has been said by noble Lords to express the great concern that there is for the standards of care and its sustainability. I thank the noble Earl for his responses, but we would like to take this away to think more about some of the issues raised tonight.
It has been helpful to have the debate and to bring out the issues. Perhaps we can now be slightly more constructive in looking at the way forward. I beg to leave to withdraw the amendment on the basis of reflecting on the issues raised.
Care Quality Commission: Morecambe Bay Hospitals
Baroness Emerton Excerpts(10 years, 10 months ago)
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Earl Howe
I agree fully with everything that the noble Baroness has said. We have in the CQC the right team to take it forward. They are very clear that there needs to be a complete refresh of the senior team where doubts emerge about the individuals concerned. We are already seeing a complete refresh of the board. I share her worry about the tabloid press and calls for heads to roll. Nevertheless, it is appropriate, in the particular context of Morecambe Bay, for there to be a close look at the role of certain individuals: exactly what they did, what they knew, when they knew it and whether what they did was either wrong morally or against the law.
Baroness Emerton
My Lords, I wish to refer to the introduction of a new, robust, single-failure regime for NHS hospitals. This will provide a more effective mechanism to address persistent failings in the quality of care, including the automatic suspension of trusts. As a nurse, I was trained to look at prevention rather than cure. Ought we to be looking at, and including in this, the preparation of trust boards, as well as the staff, looking across the consensus of the trust rather than concentrating on targets? It is often mentioned in reports that they do not look at the quality. We need to see a much more cohesive trust report.
Earl Howe
My Lords, this is one of the reasons why the previous Government introduced quality accounts, which are becoming more and more sophisticated and which focus the minds of a board on quality of care. It is easy to give the impression that we want to introduce a punitive culture into the NHS: we do not. However, there should be sanctions in the background to back up any serious failings of care. That is broadly what Robert Francis was driving at in talking about fundamental standards below which no care provider should fall. The CQC will be consulting on those standards later in the year, but I take the noble Baroness’s point about trust boards. It remains within the powers and competence of Monitor to suspend trust boards, either in whole or in part, where concerns arise over the governance of an organisation. That is a drastic power to invoke and they can take measures which fall short of it where appropriate.
Care Bill [HL]
Baroness Emerton Excerpts(10 years, 11 months ago)
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Lord Walton of Detchant
My Lords, I was uncertain whether to speak on these amendments in the presence of two past presidents of medical royal colleges, the noble Lords, Lord Turnberg and Lord Patel. I feel unable to support Amendment 58B because the medical royal colleges are not regulatory bodies. They are essentially educational bodies. They play a role in producing and monitoring the standards of qualifying examinations for those seeking to be specialists, but they are essentially educational and do not have a regulatory role, although, of course, they play an important part in advising on a whole range of health service issues.
However, I believe it is right that Amendment 58C should be inserted, because the bodies mentioned are regulatory authorities. The General Medical Council, for instance, can play a crucial and important role in disciplining doctors who have been found guilty of fraud and misconduct in medical research. This is very relevant to the qualities and responsibilities of the HRA, and for that reason I believe it right for this amendment to be included in the Bill.
Baroness Emerton
I rise to speak to Amendment 59 which includes the Chief Nursing Officer in the list of those participating in the authority. I thank the noble Lord, Lord Hunt, for his words on this point. I have raised the issue of the importance of evidence-based practice and the need for us to be able to develop research within the nursing profession where, to date, it has not been at the forefront of progress. Having the Chief Nursing Officer taking part in the work of the research authority, although perhaps not in its detailed content, will assist in raising the profile of the importance of research. It may well be delegated from the CCGs to the health trusts, where we may see professors of research, which will then encourage research throughout. The nursing profession is the largest single workforce within the NHS. It is important that we promote the idea and development of research by having the Chief Nursing Officer in the list.
While on this subject, it is encouraging to see the list in the Bill. When the Health Bill was introduced, health education was not included and the membership of Health Education England was not clearly set out. Although it does not relate to research, I would like to mention the importance of having an executive nurse on the health education board, because there is an executive doctor, but not an executive nurse. Perhaps I can return to this when we come to Report.
Lord MacKenzie of Culkein
My Lords, I rise briefly to speak to Amendments 58C and 59. The noble Lord, Lord Hunt, and the noble Baroness, Lady Emerton, rightly referred to including nursing in the Bill.
As the noble Baroness, Lady Emerton, said, the practice of nursing these days is underpinned by research. Of necessity, nurses are involved in research, and it must be right to include the Nursing and Midwifery Council and the Chief Nursing Officer in the Bill.
In debates on the Bill, we have heard a number of times that it is all too easy to exclude nurses. Whatever body they should be represented on, they so often are not there. I can go back, probably the better part of 40 years, maybe more, to when I once had the temerity to ask my matron to raise something at the hospital management committee. She said to me, “I’m sorry, nurse, I can’t, because I only attend by invitation of the group secretary”.
There have probably been about 20 reorganisations—I forget how many—since those days. However, all too often the situation has not changed and nurses remain excluded. The reason for excluding them, very often, is that the legislation does not cover it and therefore it is not necessary for nurses to be included. We now have the opportunity. Let us have nursing in the Bill. If we are going to have lists, as the noble Lord, Lord Hunt, said, I want to see nurses in it. I hope that the Committee will support that.
Baroness Emerton
I return to Amendment 59 and thank the Minister for explaining that there is no statutory requirement in this regard relating to the Chief Nursing Officer or the director of nursing. In the light of the comments that have been made about research and nursing this afternoon, will the Minister look at how we can take forward nursing research? If the structure is wrong for NHS England and the director of nursing for public health, where can we fit in a statutory requirement for research to be included? We cannot go on without having a means of recognising the importance of evidence-based practice based on research.
Earl Howe
My Lords, I heard very clearly a strong message from noble Lords on that point. Indeed, I recognised the noble Baroness’s strength of feeling in our earlier debates on Health Education England. Having noted that strength of feeling, I would like to engage with noble Lords between now and Report to see what avenues we can pursue in this area. I cannot make a specific commitment now, but I am very happy to talk further about these issues.
Care Bill [HL]
Baroness Emerton Excerpts(10 years, 11 months ago)
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Lord Turnberg
My Lords, I, too, strongly support the amendment of the noble Lord, Lord Patel. Like him, I am concerned and rather surprised that there is no mention in the Bill about the need for trusts and other providers to support their staff in continuing professional development. We really cannot afford to have any staff working in front-line clinical services not keeping up to date when we know that clinical practice changes rapidly from month to month.
New tests, new diagnostic methods and new treatments are coming along fast and furious. Unless members of staff are given the time and facilities to keep abreast of all of those, we will get poorer and more out-of-date care. As the noble Lord, Lord Patel, said, it is unfortunately the case that when health budgets are stretched, as they almost always are, CPD budgets are the first to go. Time off to attend courses or to engage in appraisals disappears quickly, as everyone in the service is rushed off their feet.
It is in just those circumstances that a stand should be made. The amendment of the noble Lord, Lord Patel, makes it clear that the LETBs must include the need for employers to allow the time for CPD development of their staff. How else will doctors, for example, be able to comply with the mandatory requirement of the GMC to revalidate at regular intervals? We have struggled both long and hard to get revalidation mandated and we cannot afford to see it eroded now at the same time as the responsibility for funding CPD is falling to employers. LETBs must be given the teeth to insist that time and support for CPD are included in their educational contracts with trusts.
Baroness Emerton
My Lords, I support the amendment but I also support what the noble Lord, Lord Patel, said, about CPD being extended to other healthcare professionals. One thing that has emerged as a barometer from the questionnaires is that, often, the culture of an organisation is affected by the fact that there has been no appraisal system and no continuing professional education built into the programme for other healthcare professionals—nurses, physiotherapists and radiographers. There is an important issue here: all staff delivering care need to have regular appraisals and regular updating of their continuing professional education.
Care Bill [HL]
Baroness Emerton Excerpts(10 years, 11 months ago)
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Baroness Emerton
“Mandatory training for health and care support workers
(1) HEE must develop a mandatory training curriculum for health and care support workers who are delivering direct care to service users.
(2) For the purposes of subsection (1), a health or care support worker shall be an individual who works in support of health or care professionals and delivers direct care to service users.
(3) In setting the training curriculum set out in subsection (1), HEE must seek to ensure that standards and competencies are developed in conjunction with the Nursing and Midwifery Council and other relevant organisations.
(4) Providers of health or care services must be responsible for ensuring that all health care support workers have completed the mandatory training curriculum in subsection (1).”
Baroness Emerton
My Lords, in her absence I thank the noble Baroness, Lady Greengross, for introducing the debate earlier this afternoon on the regulation of healthcare support workers, which opened the discussion leading to the two amendments that are down here. The first is in my name and the second in that of the noble Lord, Lord Willis, who unfortunately is unable to be with us. We wish him a speedy recovery.
I want to make one or two points by way of introduction. First, I would be remiss not to say that the Royal College of Nursing has long called for the mandatory registration and regulation of healthcare support workers. The RCN believes that it is an important part of the registration and regulation process because it has done a tremendous amount of work in talking to both registered nurses and healthcare support workers. It feels that this should be the way forward in the interests of patient safety. However, disappointed as they have been that we could not have regulation, they have moved on and are sympathetic to the amendments that we have laid down.
Mention was made of the disappearance from this setting of enrolled nurses. I went back to look at the case that was made for that disappearance and the end of enrolled nurse training. It happened because the enrolled nurses were being abused and misused by being left in charge of wards and being required to undertake tasks for which they had not been trained or were not being supervised. I have to say that the various skills currently being used by healthcare support workers far exceeds the definition of basic skills. They are doing things that might suggest that they are being abused and misused. I am sure that the House will agree that we need to do something about the situation. The Francis report requested that we look at the registration of support workers.
The question of standards leads into the amendments that we have put down. When a healthcare support worker is under the direction of a registered nurse, that nurse is working to care standards that have been determined by the Nursing and Midwifery Council. It seems sensible that the skills for care should be linked to care standards so that the registered nurse who delegates to the support worker can understand to which standards that support worker has been trained as well as the level of understanding that that support worker should have. I think that I used this example before in a debate on the health Bill, but instead of them just being taught how to carry out a skill such as taking a blood pressure, they should also understand the side effects of a raised or lowered blood pressure and what that means in terms of reporting it to the person who has delegated the task.
That brings me to the amendments we have tabled. If I may, I will move straight to Amendment 23A, which is a more succinct qualification of our first amendment and brings in all the points. It is in the name of the noble Lord, Lord Willis of Knaresborough, and is supported by me and the noble Lord, Lord Patel. The first point of the proposed new clause is that:
“Any individual working directly with patients or clients must be certified to have completed training in basic standards”.
In other words, they must go through training which equips them to have a certificate of qualification.
Secondly:
“The standards, in subsection (1), will be published by Nursing and Midwifery Council and approved by HEE”.
There should be some agreement between the NMC, which is the regulatory body, and Health Education England on subscribing to that.
Thirdly, the amendment states:
“Employers must retain a register”.
Once the support worker has been through the agreed LETB training, which would be delegated to a college of further education, they would reach the basic standard and be on a register and hold a certificate. The additional point in Amendment 23A is that it would be,
“an offence for any employer to employ an individual to work directly with patients or clients who is not registered as holding a certificate of training in basic standards”.
That would get over the point that people could go from one place to another without a valid certificate. We are interested to know how the Minister will respond to the amendment’s proposals on basic training certification in place of registration and regulation. I beg to move.
Earl Howe
I agree with the noble Lord. It would be an interesting exercise. If I can glean relevant facts from the National Health Service Litigation Authority, which is the holder of the corpus of information in this area, I would be glad to share it with noble Lords. We do not dispute that skills are an issue. They clearly are. That is why we have instigated the Cavendish review, but it is important that we set about this in the right way.
The Secretary of State has clearly stated in his mandate to Health Education England that it should work with employers to improve the capability of healthcare assistants. That will include the standards of training that they receive. In developing a strategy and implementation plan to achieve this, Health Education England will build on the Cavendish review, when it is before us, and the work of Skills for Health and Skills for Care on minimum training standards for health and care support workers.
The Government accept that the arrangements for induction, training and performance management of this workforce vary between providers. We do not duck the importance of training and I want to stress that. The Cavendish review has been tasked with reviewing how the training and support of healthcare and care assistants can be strengthened so that they provide safe and compassionate care to all people using health and social care services. The noble Lord, Lord Patel, is right that Amendment 23A and whatever recommendations emerge from the Cavendish review may not necessarily be mutually exclusive. At the same time, it surely makes sense for the Government to look at all these issues in the round before pronouncing one way or the other on prescribing specific arrangements around certification, new criminal offences or whatever the case may be.
I hope the noble Baroness will agree that the Government should be afforded the time to consider any recommendations from the Cavendish review and the respective roles of employers, commissioners, regulators and other bodies before taking further steps. At the same time, I hope that she will feel reassured by what I have said today and that Health Education England and the Government have taken sufficient steps in committing to the training and development of this workforce, and that she will feel able to withdraw her amendment.
Baroness Emerton
My Lords, I thank the Minister for his summary and noble Lords who have taken part in this debate. I think there is no doubt in anybody’s mind that this is a very important subject, which we cannot ignore. In his summary, the Minister suggested that the Government need to take this away and look at it. I think that we, too, need to take it away and look at it, and at what the Minister said. Will the Minister tell us when the Cavendish report is to be published? We understood that it was signed off two or three weeks ago, and we need to understand where it fits into the picture with the CQC. I thank the Minister for his comments. I will withdraw the amendment tonight on the basis that I will return to it later in the passage of the Bill. I beg leave to withdraw the amendment.
Care Bill [HL]
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Lord Campbell-Savours
My Lords, I should like to say a few words. My experience in all this is very much as a layman and as a tri-weekly visitor to see my mother in a nursing home. In discussion with health assistants working in the nursing home, I have found that there is a transfer between hospital settings and social care, and there are clearly disciplines and learning requirements that apply in both settings. Sometimes, in either setting, you see people who would have benefited from the training available in the other setting, particularly in the area of elderly care. To take nutrition, cleanliness and the changing of bedding, clearly the same standards apply. Often, simple tasks require a common training programme. I hope that the Minister takes the amendment very seriously.
Baroness Emerton
I entirely support the amendment on integration, particularly across the boundaries between acute and primary care. When we consider discharge policies and mechanisms, it is terribly important that those working in the acute sector understand what they need to look at to integrate with the services that will take over the care. There is division where, through the education programme, we need a holistic approach to the patient pathway.
Lord Sutherland of Houndwood
My Lords, I very much support the intention behind the amendment. It points us where we should be going. It is evident that the way in which professionals are trained deeply affects how they carry out their duties for the rest of their lives. That is a sign of good education. The noble Lord, Lord Warner, has been pointing the direction in which health and social care will and must go. It is essential to lay down the basis so that professionals accept that it is the shape of things to come.
Baroness Emerton
My Lords, I will make a few comments on the contributions made so far by noble Lords. During the passage of the Health and Social Care Act I was very strongly in favour of the regulation of healthcare support workers. We have moved on in time, and in terms of the setting up of Health Education England and the role that the other bodies are taking. There is no doubt about all the points made by my noble friend Lady Greengross, and those about Winterbourne View and people being given prison sentences; most of them were registered nurses, not support workers. We want to ensure the safety of patients. For various reasons the Government now take the view that regulation is not possible through the Nursing and Midwifery Council. Regulation is possibly a step too far at this stage.
The Francis report recommended the creation of a registration system, under which no unregistered person should deliver care to a patient, whether that be in the community or in hospital. I agree that we need to have some form of certification, and some form of safeguard that will ensure that anyone delivering care will be able to be examined. Amendment 23A, which is grouped with Amendment 23, further sets out my view, which is shared by the noble Lords, Lord Willis of Knaresborough and Lord Patel, that basic training should be given with certification, and that it is important that employers take that into account.
Lord Campbell-Savours
My Lords, from what I hear and from what I have been told, the problem seems to be that no one wants to do this job. A number of organisations have been approached, and many of them have made it clear that registration would be an impossible task. However, when you talk to healthcare assistants in nursing homes or wherever, you find that among them are some who strongly believe in it, because they want to see weeded out the people who they believe should not be practising. If they want it, and they believe that it potentially defends their professional position, why can they not be given some organisation, some kind of structure to which they can belong and be registered with, which would give them confidence within their working conditions?
I understand that the Government’s response will be the vetting and barring scheme. However, despite that scheme, there is still strong support for the principle of a registration scheme. Perhaps the Minister might give his response to that, setting out the reasons why some people do not have confidence in this vetting and barring system.
Finally, in the event that we do not make progress on this matter during the course of this Bill, the best way to deal with it might be to refer it to the Liaison Committee when it is next considering applications for ad hoc committees. Perhaps those who are interested in this subject can make a joint application to the Liaison Committee to set up a House of Lords inquiry into what the blockage has been historically, what the benefits would be, and to look at the way forward in the future.
Earl Howe
I conclude by saying to the noble Baroness, Lady Greengross, that I hope she takes some encouragement from the work that is in train, and that she agrees with me that it is right to take stock after we see the recommendations flowing from the Cavendish review later in the year. No doubt that can inform our deliberations on Report. I hope that, in the mean time, she will feel able to withdraw the amendment.
Care Bill [HL]
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Lord Willis of Knaresborough
My Lords, in the Second Reading debate on the Health and Social Care Bill, now an Act, I made the point that while we were talking about structures until the cows came home, the things that really mattered were the education and training of the staff within the NHS and the research element that gave those staff the very best tools in order to be able to care for patients and have good patient outcomes.
I compliment not only my noble friend, but the whole House, and indeed the whole Parliament, on the way in which it got behind the proposal in that Bill which is now in this one to create Health Education England as a way forward. The appointment of Sir Keith Pearson, who knows the supply side very well and has the ability to bring people together to listen to what he has to say and to be able to develop Health Education England as a real force for good, is quite outstanding. My worry is that we will start to bind the hands of Sir Keith and Health Education England, and we must not do that. What is required now is an organisation that is given sufficient flexibility and power to be able to grasp the key issues that are facing the NHS and to move forward.
I support very strongly the amendment in the names of the noble Lords, Lord Turnberg and Lord Patel, to include on the board people with relevant expertise. I am pleased that the noble Lord did not go on to say exactly who should be on that board, because I believe that that would be a step too far. But to have somebody with a real background in training, education and medical research would bring great strengths to the board.
I also support Amendment 3 in the name of the noble Lord, Lord Hunt. Indeed, I support virtually all the amendments tabled by the noble Lord and compliment him on the way in which he introduced this part of the Bill. Having a registered nurse on the board is so important. If we do nothing else in terms of the Francis report, the one thing that shines through is that you need somebody within the organisation who brings to the board those issues of quality care at every level. That is really quite exciting. I hope that my noble friend will listen to the wise words of the noble Lord, Lord Hunt, and others, and ensure that nursing is given a real place at the table, because quite frankly for generations it has not been. Nurses are no longer the handmaidens and “handmasters” of other professionals. They are in fact equals.
Baroness Emerton
My Lords, I support the noble Lords, Lord Hunt, Lord Turnberg and Lord Willis, in their recommendation that a registered nurse should be on the board.
An issue that Francis picked up after the report is that the nursing voices are not strong. He said he was disappointed in the response from the nurses. We now have to ensure that the nurses on the board are equipped with the knowledge and expertise to be able to speak out and hold their own. The training of senior nurses in standing at the board table and making their voices heard and understood on quality, safety and the patient experience is going to be very important. Therefore, it links very much with the leadership training, which we also need to address, in terms of their preparation. Perhaps the noble Earl will comment on that.
Lord Warner
My Lords, I support these amendments. I will pick up the point made by my noble friend Lord Hunt about managers. The public sector needs all the quality management it can get and many of its problems rest on the fact that we do not have a cadre of managers to take many of our public services through the difficult years ahead. The NHS is no exception.
For too long—and my own party has been guilty of it in the past—we have dismissed managers as men, and indeed women, in grey suits who are dispensable. We have to give some strong messages to HEE that if the NHS is to develop and evolve and cope with the problems ahead, we need a strong cadre of managers and we have to develop them over time. It is not too early to start now because we have a real problem not just in staffing chief executives now but in staffing the next cadre of chief executives and the middle management and development programmes for that. The Government would do well to give some strong messages to HEE and possibly even consider strengthening the legislation on this issue because it would be a missed opportunity if we do not strengthen that body of people to help us run the NHS in the coming decades.
Earl Howe
My Lords, I listened with care to my noble friend, whose experience we respect greatly. I can tell her that Health Education England’s board will need to have access to a cross-section of clinical expertise, as it does at the moment. Nursing representation will of course be very important. I assure her that we will prioritise that issue in developing the supporting regulations on membership. That is probably as far as I can go, but I recognise the force of everything that my noble friend said.
Baroness Emerton
On a point of clarification, the Minister used the term multi-professional education in relation to integrated services. We have concentrated on medicine, nursing and clinical expertise. Because we are going to be looking across the boundaries into social care, is Health Education England going to have anything to do with the social care aspect of the training of clinical specialists? We have not mentioned social care, and I wondered whether we should.
Earl Howe
My Lords, Health Education England will have responsibility for the NHS workforce, but not for the social care workforce. We will reach a group of amendments that bear closely on the issue of integration, where I am sure that we can explore the relationship that Health Education England will have with those bodies charged with delivering the social care workforce. The noble Baroness is absolutely right: there needs to be co-ordination and joined-up thinking in those areas. If she will allow, we can wait until we reach that group of amendments before debating the issue further.
Care Bill [HL]
Baroness Emerton Excerpts(10 years, 11 months ago)
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Lord Willis of Knaresborough
My Lords, I support Amendment 12 in particular. I declare an interest as an honorary fellow of the Royal College of Nursing.
When I was preparing the Commission on Nursing Education report, although we were looking at pre-registration, one of the key elements that came up time and again was that nurses were leaving their training and going into settings, within NHS tertiary care settings, primary care settings and, in particular, community settings and domiciliary settings, where the notion of continuing professional development was non-existent. People were finding an immediate barrier to even asking questions about doing things in a better way. The way you overcome that is by doing exactly what it says in this amendment. You put at the very heart of your organisation the fact that you continue to develop. Even preceptorship, the year after training, was given scant regard in many places because the nurses were so busy doing their day-to-day tasks that there was not time for management to put it in. My argument is that without putting in that training, you are less efficient, you give poorer care and ultimately the whole organisation suffers. I hope that my honourable friend will take on board this crucial business about ensuring that Health Education England is not just about training at the base level, but is about continuing to train people throughout the whole of their professional lives.
Baroness Emerton
My Lords, I will add to what the noble Lord, Lord Willis, said. A lot of work is being done on the appraisal system, but without the appraisal system leading into continuing professional development, professional development becomes ad hoc. A lot of work is being done by the noble Baroness, Lady Cumberlege on appraisal, and I believe that some work is being done by the department as well. If we could link this work with continuing professional development, I think that that would be very helpful.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the health service is dependent on having the right numbers of staff, with the right skills and behaviours. Quite rightly, patients expect the people who deliver health services to be well supported and to have the right professional and clinical skills. To achieve this, we need a system that can attract people with the right values, give them the right career advice, support the development of excellent professional and clinical skills, emphasise the centrality of providing care with compassion, kindness and respect, and ensure a workforce that is responsive to changing needs and innovations in services. That, in a nutshell, is why we have established Health Education England and the local education and training boards.
Health Education England is already established as a special health authority and is already working to put in place requirements similar to those placed on it in this legislation. Establishing Health Education England as a non-departmental public body will ensure that it has the independence and impartiality that it requires to plan, commission and quality-assure education and training for the long term. As an NDPB, it will be accountable to the Secretary of State and Parliament for ensuring that there is an effective education and training system in place. The establishment of Health Education England has been welcomed, I am glad to say, by stakeholders across the health and education system. It has the support of the Health Select Committee and the Joint Committee that scrutinised the draft Bill. It is viewed as an important step forward in promoting the development of the healthcare workforce and driving up standards.
Amendments 8 and 10 seek to ensure that Health Education England gives equal consideration to physical and mental health in the delivery of its education and training functions. I have no quarrel with noble Lords bringing us back to that familiar theme, but primary legislation is not required for Health Education England to give equal consideration to the importance of physical and mental health.
To start with what I hope is an obvious point, in establishing Health Education England, the Government are making clear their commitment to the development of the entire health and public health workforce. One of the significant weaknesses of previous workforce planning and education commissioning arrangements has been the fragmented approach, with responsibilities scattered across different bodies and silo approaches taken to considering the development needs of different professions and services. Health Education England will be different. It will be responsible for the planning and development of the whole workforce, whether in primary care, secondary care, public health or mental health. Although it will retain a strong focus on the development of different professions, it will do so with a multiprofessional remit and perspective that promotes multidisciplinary education and training where appropriate.
I would like to take the Committee back to the Health and Social Care Act 2012, which places a clear duty on the Secretary of State to ensure an effective education and training system for,
“persons who are employed, or who are considering becoming employed, in an activity which involves or is connected with the provision of services as part of the health service in England”—
which is a very wide scope. That duty is very important. It reflects the importance of education and training in the NHS and public health system, and is a key duty underpinning the Secretary of State’s duty to ensure,
“a comprehensive health service designed to secure improvement … in … physical and mental health”.
The Bill delegates the Secretary of State’s education and training duty to Health Education England, giving it a clear and unambiguous remit for workforce planning, education, training and development across England. I hope that that conveys to the Committee the direct legal linkage between this Bill and the 2012 Act in respect of the parity of esteem issue.
Clause 88 requires Health Education England to have regard to the Government’s mandate to NHS England. It is appropriate that the education and training objectives are aligned to service commissioning objectives in this way. It is especially relevant in the context of this amendment because the NHS England mandate requires mental and physical health conditions to be treated “with equal priority” and to,
“close the health gap between people with mental health problems and the population as a whole”.
The Government’s mandate to the Health Education England Special Health Authority reflects this and requires Health Education England,
“to focus on the mental health workforce”.
I listened with care, as I always do, to the noble Lord, Lord Rix. I simply say to him that Health Education England can support better education, training and development for staff so that they can better support people with learning disabilities and difficulties. The core components of education and training for all staff should be to treat people with kindness and compassion and communicate well with all patients and carers. That, I hope, goes without saying, but it is particularly relevant to those with learning difficulties and disabilities. In saying that, of course I recognise that there are certain specialist skills that people in that field require.
Amendment 12 relates to continuing professional development. I absolutely recognise that the continuing professional development of healthcare workers is important. This is enshrined in the NHS constitution, which places a commitment on all employers that supply NHS-funded services to invest in this area and provide their staff with the support and personal development that they need, as well as access to appropriate training to enable them to fulfil their duties.
Health Education England will play a crucial role in providing leadership in this area. The mandate that the Government published only recently for the Health Education England special health authority sends out a clear message that the staff working in our NHS and public health system are the health service’s most precious resource. We must do all we can to ensure that staff have the right values, training and skills to deliver the very highest quality of care for patients. To support the development of the existing NHS and public health workforce, the mandate sets out that Health Education England will work with Local Education and Training Boards and healthcare providers to ensure professional and personal development continues beyond the end of formal training to enable staff to deliver safe and high quality health and public health services, now and in the future. This will include supporting those staff who may wish to return to training.
I hope that those remarks are helpful to the noble Baroness. To cover a number of questions that were put to me, the noble Baroness, Lady Wheeler, asked about the Royal College of Psychiatrists report. We very much welcome the report. The Minister for Health and Care Services will be attending the report’s launch on 19 June and will be setting out what the Government will do to respond to the challenge that the Royal College has articulated.
The noble Lord, Lord Warner, asked what Health Education England will do to address the issue of reliance on locums and agency staff, a very pertinent question. Health Education England can make a significant contribution in this area. Better workforce planning, linked to service and financial planning, is a key aim of the new system that should ensure less reliance on locum and agency staff.
The noble Baroness, Lady Wall, asked me what Health Education England was doing to support career development for healthcare assistants. The capability of care assistants, and public confidence in that group of workers, is of increasing importance. Health Education England will work with employers to improve the capability of the care assistant workforce, including those in the care sector, as well as the standards of training that they receive. Health Education England will develop a strategy and an implementation plan to achieve that, building on the Cavendish review, which will be published quite soon, and on work by Skills for Health and Skills for Care on minimum training standards. The strategy should cover job roles, recruitment, induction, training standards and transparency, as well as identifying opportunities for career progression. I hope that those comments are helpful to the noble Baroness.
Baroness Emerton
Amendment 19, on the importance of practical-based training in the education of clinicians, follows on from what the noble Baroness, Lady Wall, and the noble Lord, Lord Hunt, have just said. Because we are moving so quickly in healthcare delivery and the integration and multi-professional working, perhaps we should be looking at how holistic care, which is what I think is being referred to—the ability to see the patient pathway from primary care through to hospital care and back out to primary care—can be a pathway that nurses in particular are trained to be able to execute and to ensure that the transition from one to the other is smooth and without hiccups.
The complaint that we are getting at the moment from the public is that there is a complete block in some areas where the staff are just not aware of what the discharge policies should be and what is at the other end. That picks up the point raised by the noble Lord, Lord Hunt, about the practical skills and the need to look at the curricula from the academic area and put them back into the practice area.
Amendment 14 concerns HEE’s staffing and skills mix in carrying out its functions. When we look at the skills mix, what we are really looking for is an evidence base. We want to look not at static numbers but at evidence based on the safety level. If the minimum is based on the safety level, we are looking at something that can be a useful guide on which to base our working.
Lord Willis of Knaresborough
My Lords, I shall speak to Amendments 26 and 33. Like the noble Baroness, Lady Emerton, I also emphasise the importance of Amendment 19. While it is a rather small amendment, it has huge significance.
Talking to people from Health Education England recently, I was struck by the desire in the Francis report about the whole issue of practical training. When a significant amount of the training of medics, doctors and nurses is carried out in practical situations, one asks how you can get the sort of situations that the noble Lord, Lord Hunt, referred to. When nurses spend 50% of their time in practical situations, how do they come out of their training not ready to be deployed in certain areas? To be fair, when you see the time and the effort that is put into mentoring in many of these settings and the quality of that mentoring, you start to realise that there is a big problem. I hope that on Report we can bring back some of the issues relating to mentoring, or at least get some satisfaction from the Minister that this issue will be taken incredibly seriously in health education. If it is not, we will continue to have people who in theory are trained well but in practical terms are really not as fit for purpose as they should be. That will not be their fault; it will be our fault.
Amendment 26 very much echoes the thoughts behind Amendment 27. I particularly welcome in Amendment 27 the idea of having a 10-year plan. In fact, five years is short-term. It is better than what we have at the moment, but a 10-year plan is a really good idea, and I am sorry that I did not table that amendment. I saw it but thought that we would not want two amendments along the same lines.
On Amendment 26, Clause 85(1) of the Care Bill defines Health Education England’s responsibility as ensuring that,
“a sufficient number of persons with the skills and training to work as health care workers for the purposes of the health service is available to do so throughout England”.
Who could disagree with that? What a noble suggestion. While that would clearly include both healthcare support workers and nurses, the mandate, which was helpfully provided by the Minister before this debate, sets out a strategic national role in relation to medicine, dentistry and pharmacy in paragraph 5.2.6, and proposes a five-year workforce plan for “smaller specialties and professions” in paragraph 5.2.7, but provides little information on how the nursing workforce or the healthcare support workforce is to be undertaken and implemented. Does that not tell us all we need to know about what the priorities still are? While we have good words within the Bill, we do not have anything within the mandate that backs them up in a real sense. Midwives and health visitors suddenly appear, but I think that the commitment to having a comprehensive workforce under a five-year plan is worth really striving for.
Amendment 33 looks at the future guidance and standards for safe levels of staffing. I have a real problem with allocating numbers. When I was in another place, I remember arguing with the then Government about class sizes for years 1 and 2 in primary schools, where there had to be 30 children or fewer and the 31st child had to go somewhere else. You realise that, depending on the setting, you can do all sorts of different things. What we must not do is tie down the hands of high-quality management in being able to deploy staff in the most appropriate way. What matters is getting the mix of staff absolutely right. I hope that we will return to the question of staffing levels because it is fundamental but, frankly, we could go down the wrong road if we took it too seriously.
Care Bill [HL]
Baroness Emerton Excerpts(10 years, 11 months ago)
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Baroness Emerton
My Lords, I thank the Minister for the introduction to the Care Bill. This legislation provides the missing links in the Health and Social Care Act 2012 and sets out clearly the responsibilities and the part to be played by local authorities in providing the missing links towards achieving a fully integrated service which aims to provide holistic care, from maintaining pathways in well-being, disease prevention, sickness, care and support through to end-of-life care.
The Bill also shows how the costs of the services will be met, ensuring that advice and understanding will be available for all. The Bill’s success depends on breaking down the organisational and professional boundaries that have prevented progress previously. It will succeed only if its three parts are fully discussed in Committee and then implemented in line with the comments made at Second Reading. The Committee will address Part 3, followed by Part 2 and then Part 1. I firmly believe that Part 1 will not succeed unless Parts 2 and 3 are fully understood and addressed.
I am a retired nurse and a carer so I approach the Bill from an essentially practical perspective. I shall therefore start with the provision making Health Education England a non-departmental body. This change is vital if the body is fully to fulfil its responsibilities, as the noble Lord, Lord Willis, said. The Secretary of State will issue a mandate and this will be of great value to Health Education England, which must work in tandem—and within a defined budget—with a wide range of specialities and many different bodies. The Government’s addition of Clauses 87(5) and 93(3) from the draft Bill underlines the fact that planning for a period of longer than one year is essential when considering workforce requirements such as education and training which involve a long lead-in period. Clause 88 sets out the importance of having sufficient numbers of skilled workers to meet the health and social care requirements. LETBs will have responsibility for planning for the workforce and the skills requirements for a defined area but they must also take account of the wider geographical requirements if specialities and the time element are to be addressed, especially if this is to be cost-effective.
Healthcare assistants—support workers—have been a subject of concern regarding training and the review by Camilla Cavendish which the Prime Minister requested is due shortly for publication. Skills for Health has published a list of skills that should be part of the training for healthcare assistants. As we know, however, simply teaching a skill without providing the background knowledge is of no value in delivering quality care. Both Robert Francis QC and the noble Lord, Lord Willis, recommended mandatory training. I hope that the Government will seriously consider that after considering Camilla Cavendish’s recommendations. I ask the Minister seriously to consider mandatory training programmes which might link skills training to the NMC’s care standards, which are the core of the nurse training curriculum. That would provide a greater understanding for both the healthcare assistants and for the registered nurses who are responsible for supervising and delegating to the healthcare assistants. If high-quality care is to be delivered in the NHS, in local authorities and, importantly, in the independent sector of nursing homes and care homes, where standards are not always compatible with high-quality care, then the matter of training for healthcare assistants must be dealt with urgently.
Health Education England has an enormous task in improving the provision of workforce data on all disciplines and clarification is required about the part to be played by the Centre for Workforce Intelligence and how this slots into the Health Education England programme. Achieving the right numbers of appropriately qualified people who are in the right place at the right time is an enormous task but it is essential if safe, high-quality care is to be delivered to the satisfaction of patients and their families. There are already examples of shortfalls in all disciplines but in nursing there are great disparities between those who produce high-quality care and those who do not. These disparities usually reflect the ratios of registered nurses to healthcare assistants and the required level of supervision. The right numbers in the right ratios are the most cost-effective and care-effective way of delivering high-quality, safe patient care both in the NHS and in local authority health and social care services. I hope that the two vital issues of healthcare assistants’ training and the ratio of registered nurses to healthcare assistants can be sorted out as a matter of urgency.
Continuing professional development is crucial to the future of integrated care programmes. It is important that the values set in the NHS constitution and within healthcare trusts, primary care and local authorities are understood by all employees and employers. There is a need to encourage onward development of all employees by implementing a sound appraisal system which reflects the needs and aspirations of each employee and results in an individual CPD programme. If this is not rigorously followed through on, the issue of burnout and loss of commitment will become apparent. In such circumstances morale falls and healthcare provision can fail. Such a culture is not conducive to high-quality care and is similar to that experienced in Mid Staffordshire.
I turn to the Health Research Authority. Evidence-based practice and innovation depend on research findings. It is a great disappointment that the constitution provided in the Bill is stated in such general terms that it is impossible to determine whether there will be multiprofessional representation on the board or among the employees. All healthcare professionals now require a degree but the responsibility for research has until now remained with the medical profession and little attention has been paid to the other healthcare professionals when considering representation on boards, in committees and in terms of funding. How can innovations be developed without research backing? Promises were given verbally during the briefing for and passage of the Health and Social Care Act but there is no evidence that any notice has been taken.
One good example of the outcome of some research done by a Florence Nightingale Foundation scholar— I declare an interest as president of the foundation—was the introduction of care bundles. As a result of that scholarship the mortality rate in people suffering from three long-term conditions was reduced to below the average SMR. We need more projects and research like that to ensure that practice is based on evidence and sound research. I ask the Minister to ensure that there is more investment on the multiprofessional side of research as well as on the medical side.
Part 2 of the Bill refers to care standards. It is pleasing to see that the Government have taken steps to legislate on some of the Francis report on the Mid Staffordshire inquiries. The CQC’s role in identifying failing trusts on the basis of quality as well as financial concerns is welcomed by nursing staff who strive to maintain delivery of safe, high-quality care to the satisfaction of patients and relatives. Work by the CQC is ongoing and we will study it as an important step forward.
Part 1, on care and support, is a crucial part of the Bill that fundamentally sets out the responsibility of local authorities in the fields both of preventing the need for care and support and promoting well-being. However, the critical and most difficult part is promoting the integration of care and support within the health services. Fundamentally, integration is vital and the most important ingredient in successful health and social care, bringing together a huge band of people who will need educating, training and an understanding of the true meaning of holistic care that enables a patient pathway to be clear and understandable by those delivering the care, whether within the aegis of the local authority, the NHS or the independent sector.
In summary, the Bill is a welcome step forward in tackling the issues that so badly needed to be addressed. It will influence and persuade health and social care providers to provide the population they serve with quality and satisfaction.
NHS: Out of Hours Service
Baroness Emerton Excerpts(11 years, 1 month ago)
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Earl Howe
I am aware of teething problems in two particular areas of the country, but we know from the pilots of NHS 111 that there is a high rate of patient satisfaction with the service. As noble Lords will know, NHS 111 is designed to put the caller through to the right service first time around, whether it is a nurse, a doctor or an ambulance, if that is required. There are bound to be teething problems, and rolling out a service like this across the country is, of course, a major task. But the concept of increased flexible access to healthcare and advice is absolutely right, and we are determined to see the service work very well for everybody.
Baroness Emerton
My Lords, in his Answer to the original Question, the Minister said that action would be taken if the service failed. Who will actually take the action under the new system once the Act becomes actionable next weekend?