Mid Staffordshire Foundation Trust Inquiry
Baroness Emerton Excerpts(11 years, 1 month ago)
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Earl Howe
My Lords, it is a little early to say what legislation we will need, but I can tell my noble friend that we can deal with the duty of candour by secondary legislation. It may be that many of the follow-up actions to Francis can be done without any legislation at all. However, primary legislation would appear to be the obvious route when statutory roles are to be changed.
With regard to the chief inspectors, the only firm decisions we have taken so far are to appoint a chief inspector of hospitals and a chief inspector of social care. We are looking at the merits of a chief inspector of primary care but we need to make sure that there is a genuine issue that needs to be addressed by way of a chief inspector role rather than leaving the CQC to perform its role in the normal way. Further details will be forthcoming at an appropriate time.
Baroness Emerton
My Lords, I would like to mention nurse education. The suggestion of having some front-line experience before entering university is, philosophically and practically, very good if it can be worked, but it raises all sorts of questions. I spoke to a healthcare support worker a few weeks ago who said that all the students who come on to her ward tell her, “I wish we had had this experience that you are getting before going into training”, so there is evidence that many of them would like to have that kind of experience. However, this raises the question of their supervision during that time. Will there be adequate numbers of trained staff to supervise the continuing support workers as well as those who are pre-nursing apprentices, or whatever?
The logistics of this are going to be important to work on. We need to know whether the Government will look at minimum staffing levels. Where there are enough registered nurses and the minimum is stated, there should be means whereby registered nurses will be available whenever demands on patient care escalate, such as during a time of winter problems, rather than abusing and misusing the support workers. There is a tremendous amount of work to be done on that.
There is also the role of the Nursing and Midwifery Council, which has responsibility for regulating the pre-nursing standards. I hope the Government will ensure that the council takes an active part in this pre-nursing experience, because that will be important. I urge Ministers to have this minimum staffing looked at, if that is possible. I am extremely disappointed that the Government are not prepared to take on the regulation of these support workers because I fear that we may find ourselves having similar problems as in the past, unless we have some regulatory system.
Baroness Northover
My Lords, I remind noble Lords that brief questions only are called for after Statements, and that the briefer they are, the more colleagues will be able to get in.
NHS: Mid Staffordshire NHS Foundation Trust
Baroness Emerton Excerpts(11 years, 2 months ago)
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Baroness Emerton
My Lords, I, too, thank my noble friend Lord Patel for raising this debate, especially for the way in which he introduced the positive side of his recent care to show how it is possible to have a patient pathway that results in high-quality care.
The 294 recommendations demonstrate the depth of the inquiry that has taken place, which must provide some comfort to the relatives and friends who witnessed the very distressing care that was given. The Government now have the responsibility to respond as to how these recommendations are to be met. The relatives, public and professions will be interested in the outcomes, for nobody could wish the same situation to happen again. This is said after any inquiry, of course, but this in-depth report requires commitment to meet the recommendations and necessary changes that will result in safe, high-quality care being given with compassion and respect. It is true that the nursing profession has emerged under a cloud, which means that the 20-plus recommendations relating to nursing require intense scrutiny and consideration for implementation.
My first point is to focus on a patient-centred culture. Having researched previous inquiries, very little or nothing is mentioned about culture. However, as has already been said this evening, unless everyone from the top of the organisation—the chairman and the board—to the ward sister who is in charge of the ward, is aware of the values and standards that are set, and unless they are open, transparent and activated, we will have another Mid Staffs. To avoid this, there must be strong cultural leadership. Do the Government intend to grasp this specific recommendation, which requires more than written codes and standards? It requires practical, behavioural and experiential learning in a multi-professional context within bespoke learning environments.
High-quality and safe care delivery is dependent on nurses who are well prepared, in theory and in practice, with enough time to deliver holistic care with compassion and respect. This is possible only if the workforce plans are such that there are sufficient numbers of registered nurses to supervise the non-registered support workers, as the report clearly shows. Recognising that workforce planning has to be contained within budgetary constraints, it would nevertheless be helpful if minimum staffing ratios of registered nurses to non-registered nursing support workers could be established, along with, I hope, the recommendation that NICE be charged with the responsibility for assisting in this development. I trust that the Government will agree.
It is a long overdue recommendation that every person giving personal care should be trained, which was also taken up by the noble Lord, Lord Willis, in his report. Work in progress for the training of healthcare support workers, which is soon to be published for consultation, will be a welcome step towards, I hope, mandatory training programmes that will lead to registration.
The report also recommended the regular updating through post-registration training following appraisals for registered nurses, which is a necessity. While examining the recommendations from this report, we must also remember that there is an army of excellent nurses, midwives and health visitors spread over the country who are delivering high-quality and safe care, day after day, to the satisfaction of those for whom they care. However, it is vital that there is regular updating though post-registration training, as this is of such importance in this time of rapid developments in medical science. Moving into the integration of health and social care requires understanding the patient pathway from the beginning to the end, with nurses playing a vital part in that smooth transition from one part of the service to the other.
Care Services: Elderly People
Baroness Emerton Excerpts(11 years, 2 months ago)
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Baroness Emerton
My Lords, I too thank the noble Lord, Lord Turnberg, for raising this debate. I declare an interest as in the register, and add that I live in a retirement village, I am elderly and I live in a rural area where the boundaries have a postcode lottery as far as health and social care are concerned.
The Health and Social Care Act will be enacted in one month. There is a mandate from the Secretary of State to the Commissioning Board and guidance from the Commissioning Board to the CCGs. We have the theory and we must now enter the practice. The demand now and in the future, as has already been mentioned, will increase among the growing number of the elderly in the population, and we need to ensure that their health is maintained, disease prevention addressed and high-quality, safe, acceptable care given when required, with the emphasis on independent living in the community and, where necessary, adequate support given to allow this to happen. For example, prevention of admission to hospital teams can supply the necessary support to the elderly living alone to remain in their home surroundings, where they will benefit more than they would from an admission to hospital that would be more costly and open to possible cross-infection, leading to a longer recovery period. This is a cost-effective and care-effective way forward.
My first question to the Minister regards integration of organisational services and professional boundaries. What steps are the Government taking to ensure that the theory of the Act, mandate and guidance is being followed, with required training for all concerned? The reason for this question is that currently in many places there is a chaotic situation where, through the lack of training and understanding, care pathways are disrupted and there is evidence that services are not running smoothly and the safety of the patients is in question.
Currently the ambulance services are on red alert due to winter pressures and there are reports of ambulances that are unable to unload patients causing a backlog, with patients being cared for either in the ambulance or in a cold, draughty corridor for long periods before A&E takes over because of the four-hour wait deadline. Those ambulances therefore are not free to take any calls or discharges home. About 10 days ago at 10 pm, there were eight ambulances stuck for over an hour at our local hospital. Last night at 9.30 pm, I checked the local situation. There were four ambulances outside the hospital. One had been waiting for one hour and 15 minutes, one for 36 minutes, one for 20 minutes and the other for 10 minutes, with the crew looking after the patients. It appears that sometimes, to alleviate the logjam, one crew will care for two patients—two ambulance loads—in order to free up an ambulance. It would seem that there are insufficient staff to relieve the ambulance crews and, if they do, it starts the four-hour waiting time clock. The circumstances that I mention involved a majority of elderly patients. Can the Minister assure noble Lords that the Government will take steps to ensure that every opportunity is taken to improve the integration of services in health and social care?
Innovation and research is my next area of concern. The care of the elderly has lacked funding for research into physical and mental conditions, and this situation needs to be rectified as a priority. However, there have been examples of excellent innovations being developed through specific studies undertaken by healthcare professionals as part of scholarships or fellowships. Two come to mind; one involved a nursing scholar who, on an international study, was able to learn about the early detection and diagnosis of melanomas and, on return to this country, has followed this up with a training programme for GPs. The second example was someone who, on her return from the USA, aimed to reduce the mortality rates by introducing specific care bundles. Medical and nursing staff became engaged on her return, with excellent results and, in many places, there is a marked reduction in mortality rates as a result. Can the Minister assure us that there will be an equitable amount of funding for multiprofessional research and innovation specially allocated to physical and mental health, including social care for the elderly?
No Act, mandate or guidance will be effective unless there is inspirational leadership. In my experience, such leadership is not learnt by attending a course for senior managers; it has to be bespoke and fitted to the person’s potential and ability to set the values necessary for high-quality, safe and cost-effective delivery of care. I am president of the Florence Nightingale Foundation and we are able to fund 19 leadership scholars each year. They go through a bespoke leadership programme, funded mostly by the Burdett Trust for Nursing, as well as by contributions from other smaller charities. This has resulted in scholars being promoted and successfully leading services. I ask the Minister if this matter could be explored further with the NHS Leadership Academy and Health Education England to examine bespoke approaches to specific services, especially, and as a priority, to those concerned with the care of the elderly.
Health: Healthcare Assistance
Baroness Emerton Excerpts(11 years, 3 months ago)
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Earl Howe
No, my Lords, it is not purely a matter of finance. Our view is that what really matters in this context is the competence and training of the individual involved. We are not oblivious to the concerns in this area. That is why we have already announced a number of further measures to support healthcare assistants. For example, we have just created an innovation fund of £13 million for the training and education of unregulated health professionals. The Care Quality Commission will undertake a review of inductions for care staff to make sure that nobody can provide unsupervised help without an appropriate level of training, and we have the work currently being done by Skills for Health and Skills for Care. Their report has now been received and embodies suggestions for a code of conduct and induction standards for health and social care workers.
Baroness Emerton
The Minister mentioned supervision. The voluntary register does not necessarily cover the total safety of patients unless they are supervised. There is an issue about the minimum levels of registered nurses who can supervise support workers. When will the Government look at minimum standards for the registered nurses to enable sufficient supervision? The evidence base is that effective care and cost-effective care are reliant on the number of registered nurses who can supervise support workers.
Earl Howe
The noble Baroness as ever raises an important issue. She will know that the code of conduct for nurses specifically covers supervision where necessary. My department has instigated a number of measures to support local decision-making to get skill mix profiles right. They include the QIPP programme, which is a key driver for getting the skill mix right through producing tools and programmes in that area. The NHS Institute for Innovation and Improvement supplies case studies and other resources to help NHS provider organisations deliver their QIPP strategies, and NHS employers also deliver guidance and support to help employers better plan their workforce.
Nursing Quality and Compassion: The Future of Nursing Education
Baroness Emerton Excerpts(11 years, 5 months ago)
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Baroness Emerton
To ask Her Majesty’s Government what is their response to the recommendations of the report of the Commission established by the Royal College of Nursing Quality and Compassion: the future of nursing education.
Baroness Emerton
My Lords, I am grateful to have this opportunity to seek the Government’s response to the commission looking at quality with compassion in the future of nursing education. First, I pay tribute to the Royal College of Nursing for commissioning this independent commission at such a critical time in the life of the nursing profession and congratulate the noble Lord, Lord Willis, as chairman, and his team of commissioners. I also thank those who gave the evidence that resulted in such a clear, comprehensive report with 30 recommendations, all pointing to urgent action being required of the profession it if it is going to be equipped to deliver high-quality care with compassion. It is so desperately needed today and will be very much needed in the future with growing demographic trends and the increase in the elderly population with increasing healthcare needs and, at the same time, rising costs of treatment. Within the last week, we have had the example of an MP describing the terrible treatment her dying husband received from nurses. At the other end of the spectrum, the NHS Commissioning Board’s chief nursing officer, Jane Cummings, introduced her vision of nursing with a culture of care, compassion, courage, commitment and competence for the future.
I declare an interest, as recorded in the register, but in particular as someone who has been closely involved in developing the profession’s move into higher education, and the introduction of Project 2000, as a chair of the regulatory body, the UKCC. The Willis report clearly sets out the time taken since the Briggs report to reach the point we are at 41 years later, on the eve of a graduate programme being fully implemented in September 2013. When introduced, Project 2000 produced many adverse comments, as the report says, due to inadequate preparation of all concerned, in the universities and the providers. By not working together, we are experiencing adverse comments as to whether it is necessary for graduate training to give compassionate care. This report demonstrates that registered nurses, educated at degree level, are more than equipped to deliver high-quality compassionate care. It says:
“The public needs to know what it can expect of registered nurses educated at degree level. Stakeholders should scale up recruitment campaigns and other measures, including dialogue with the media, to promote better understanding of contemporary nursing and nursing education and dispel the myth that better educated nurses are less caring”.
Perhaps I and colleagues have not had the courage to stand up and be counted to ensure that the 41-year gap did not exist. The document goes on to identify the urgent need to supply an academic nursing workforce and guarantee its future quality. The NHS Commissioning Board, the CCGs, Health Education England and the local education boards hold the responsibility for commissioning the right number of students to fill the right number of places to deliver the patient care pathways for well-being, public health, hospital care, and community care through the health and social care services, not forgetting the voluntary services.
The mandate to the NHS from the Secretary of State does not include Health Education England. This is funded directly by the Secretary of State but there does not appear to be a mandate, only an outcome measurement. This is but one of the 30 recommendations. My question to the Minister is: how will the Government ensure that what is necessary will be provided to enable the responsible bodies to adopt the recommendations of the report? We cannot afford a further delay in implementing these recommendations, as has been the history of Project 2000 and graduate training. We should not forget that the initial graduate registration is not the end; there must be provision for professional development and postgraduate development, with investment in research to allow evidence-based practice and innovation.
I have listened to a number of recent briefings and the evidence to date is that the medical professions—I exclude the medical professionals present—have little or no recognition of other professions’ contributions to delivery of care, research or innovations. Again, this is probably the professions’ fault for not speaking loudly enough to be heard and included or providing the evidence to support their case. It may also be a reflection of the status of the nursing profession as viewed by other members of the health teams which is now beginning to erode the public’s view. The answer surely must rest in the hands of the members of the professions.
The serious current economic situation presents many challenges. However, the evidence to date is that the delivery of high-quality care is cost effective in reducing complications, early discharge and reduced mortality—in other words, high-quality care is not only cost effective but safe and acceptable to the public. The recommendation relating to workforce planning describes the need to address skill mix. It states that there is an urgent need to revisit the workforce policy and skill mix and suggests:
“A planned programme of regulation should begin with the mandatory registration of all staff who deliver patient care”.
This, of course, includes support workers. It is a false economy not to follow this recommendation. Although the Skills for Care and Skills for Health bodies are due to report in January, it is a requirement of the Act to have a voluntary register.
The report recommends that there should be mandatory training and registration for support workers. Can the noble Earl please give an assurance that this issue will be revisited? At Third Reading of the Health and Social Care Bill it was said that the costs would be too high. Is it possible for a more recent up-to-date analysis of the cost to be carried out, as the one quoted was taken from a 2009 cost of a housekeeping scheme which does not equate to the work of the healthcare support workers? There is a growing awareness within the profession and among the public that there are insufficient registered nurses in some parts of the health service, more especially on wards for the elderly. However, there is a higher ratio of registered support workers where most in-patients have multiple conditions and require the skills of registered nurses. Action is required to produce a more accurate and sensitive workforce plan.
Time does not allow me to explore more of the report and its recommendations, but it is essential to note that, despite all the recent bad press and the criticism of the nursing profession, there is evidence of excellent care being given by dedicated, caring and compassionate nurses and support workers. It is also encouraging that the students interviewed showed great enthusiasm for the profession they had chosen, and were determined to hold high the traditions. Where this is obvious, it reflects good leadership of the profession and an organisational culture that fosters high-quality, compassionate care within the framework of the NHS constitution. I hope that Her Majesty’s Government will take on board the recommendations so ably set out in the commission’s report.
Winterbourne View
Baroness Emerton Excerpts(11 years, 6 months ago)
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Baroness Northover
My Lords, I have been keeping a tally and it is the turn of the Labour Party and then the Cross-Benchers.
Earl Howe
My Lords, the noble Baroness makes an important point. We have been clear that those who lead organisations where people suffer abuse or neglect should be held accountable. We have made it clear that there is a gap which needs to be addressed. A range of options is available through regulation; for example, by barring people from running care homes or hospitals ever again or, indeed, through criminal sanctions. As I have mentioned, very soon we will publish our final recommendations on what more can be done to prevent abuse and protect those who are in vulnerable situations.
Baroness Emerton
My Lords, I thank the noble Earl for his response in terms of support workers, and particularly on challenging behaviour. My past experience nearly 20 years ago of decanting hundreds of patients from large institutions satisfactorily into the community was due to the fact that the psychologists made an independent assessment of each individual of their clinical and environmental needs, and thus the training needs of the support workers. Can the Minister assure us that a holistic approach in terms of multi-professional involvement will be taken, and that it will particularly be led by evidence-based psychologists who understand challenging behaviour?
Earl Howe
I agree fully with the noble Baroness. The aim and aspiration for this group of individuals is that they should benefit from personalised services. What that means is that their needs should be individually assessed professionally by multi-disciplinary teams. The noble Baroness did not do this, but there are some who suggest that we need to get rid of in-patient services altogether. There are individuals who will continue to require in-patient services, but these should be used only in very limited cases. We need to aim towards a situation where no one is sent unnecessarily into in-patient services for assessment and treatment. We know that that has not been happening. For the small number of people for whom in-patient services may be needed for a short period, the focus has to be on providing good quality care that is safe, caring and open to the community, which is another important aspect, and that people can move on from these services quickly. Planning starts from day one to enable people to move out of the in-patient setting into more appropriate care as quickly as possible. That comes back to intelligent commissioning.
NHS: Mental Health Services
Baroness Emerton Excerpts(11 years, 7 months ago)
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Baroness Emerton
My Lords, I, too, thank the noble Lord, Lord Alderdice, for raising this important debate. Yesterday morning I was listening to Radio 4 and was somewhat taken aback when they said it was mental health week. A church service was being relayed from Epsom, I think, where there had been a great cluster of psychiatric hospitals. I really did not know that there was such a thing as mental health week, so I confess my ignorance. The Government had a No Health Without Mental Health strategy. I would add, no health without mental health, patient well-being, public health and physical health; in other words, a holistic care pathway.
I am a retired nurse and also a mental health carer. I concur wholeheartedly with the other speakers, particularly the noble Lords, Lord Alderdice and Lord Layard, about the benefits of psychological treatment and also how scarce it is. I say that with very definite first-hand knowledge—the scarcity is having an effect on the person I care for.
Much has been achieved in the provision of mental health services, but against the current situation of economic austerity and consequential cutbacks we are seeing areas where services are definitely suffering. I can give an example. Recruitment to mental health care nursing programmes is excellent, but the cutbacks in student numbers will have a long-term effect on people’s readiness to come into nursing as registered nurses. Already the CQC has recorded that the situation has led to an increase in support workers to fill the gaps left by registered nurses. This is a false economy as the evidence is clear that if the ratio of registered nurses to support workers decreases, the quality of care delivered is affected. Can the Minister say whether the Government will address the long-term effect of reducing the student intake and the adverse effect on patient care, and that the reduction of the ratio of registered nurses to support workers will be re-examined? Further, will the support worker training programme become a mandatory training programme, not leading to a voluntary register? I know that the noble Earl will not be surprised to hear me say this yet again.
Implementing the holistic care approach will be assisted by the Nursing and Midwifery Council. The care standards it is introducing are to be implemented in November this year in all universities preparing nursing students in all specialties to gain 50% theory and practice in each. This is further assisted by the Chief Nursing Officer’s recently published vision of developing a culture of compassionate care. The values and behaviours of the vision are that at its heart are what are described as the “Six Cs”—compassion, care, competence, communication, courage and commitment.
However, as has already been mentioned by several speakers, there are still many barriers between the different professional groups: the NHS, local authorities, the third sector and the independent sector; they all need to be broken down. This requires a special kind of leadership that can effect change through not only a detailed knowledge of each organisation and how it works, but also the personal leadership qualities of persuasion and influence. This needs to be recognised within a defined government strategy with a given time-span. When the large psychiatric and mentally handicapped, as they were then, learning disability institutions were closed, there was a clear strategy with a timetable to address the situation. Many speakers have referred to the outcome framework, and surely something could be built into it. That would provide a definite target date for working towards a cohesive service and, in turn, it would allow for the development of the holistic care pathway.
Mental health services present a complex field of practice with an enormous plurality of providers and stakeholders. Added to this are the demographic profile of an ageing population and workforce, and a loss of experienced practitioners due to the financial cutbacks. Against this background, commissioners of services call for strong leadership that understands the complexity of conditions and has the sensitivity to know that providers are equipped to deliver high quality services. Would the noble Earl consider that there might be an opportunity for the Government to highlight the need for such leadership qualities and build this into the policy requirements? In the absence of high quality leadership, the culture of mental health services will deteriorate, leading to a fall in the quality of practitioners and the services provided, along with a lowering of standards. Can Her Majesty’s Government allow that to happen to this very vulnerable group of the population? I think not.
Health Research Authority (Amendment) Regulations 2012
Baroness Emerton Excerpts(11 years, 11 months ago)
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Baroness Emerton
My Lords, the conversation today has been limited to medical and health research. During the passage of the Bill, we had long debates about multiprofessional involvement being included in the research. I am very concerned that the conversation has been very much geared towards medical and health research and has not mentioned the fact that there are healthcare professionals other than those involved with medicine.
Earl Howe
The noble Baroness is right to draw attention to that omission in my coverage of these instruments. Of course, she is right that there are many different kinds of research that will involve the HRA in one form or another. I have emphasised only the medical and pharmaceutical elements of the HRA’s remit, because these matters were high up on the agenda of the Academy of Medical Sciences when it produced its report in the context of UK plc.
However, the noble Baroness should bear in mind my remarks about joining up health research and social care research. The HRA will co-operate with various bodies for the purposes of creating a unified approval process, not just for health research but to promote a consistent national system for research governance generally. Where this includes a social care or nursing element, the HRA will work closely with the relevant bodies to promote processes and standards that are consistent with the NHS and social care elements.
Health and Social Care Bill
Baroness Emerton Excerpts(12 years, 1 month ago)
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Baroness Emerton
“Power to register health care support workers in England
(1) Health care support workers in England may enter a voluntary register assured by the Council for Health Care Regulatory Excellence, provided they have attended an assured training programme prior to entry on the register.
(2) The assured training programme shall be mandatory for all new health care support workers from 1 April 2013.
(3) The Secretary of State shall develop a Code of Conduct for all employees (whether or not entered on the register) who are providing care to NHS patients (including employees of local authorities) who are seeking to develop the necessary competencies for health care support work.
(4) The Secretary of State shall review the procedures for training under this section, and its benefits or otherwise, within three years of this Act receiving Royal Assent.”
Baroness Emerton
My Lords, the amendment concerns the power to register healthcare support workers in England. I shall try to be brief, as we had a long and thorough debate on this matter on Report and I have studied the Minister’s response to my amendment at that stage. I have had protracted discussions between Report and now with the noble Earl and officials, and I thank them most sincerely for the time and effort they have put into trying to meet my requests.
Healthcare support workers form a very large part of the workforce, whether they are in the employment of NHS hospitals, community services or local authority services, providing care in people’s homes, or in the large number of nursing and residential care homes. We should not forget the role played by social workers, which often overlaps with the role of healthcare support workers, and vice versa.
Many noble Lords have said in previous debates that large numbers of support workers provide high-quality care, and they have received some training in order to do that. It is not likely that this large number of support workers will decrease with a growth in demand from the rapidly expanding number of elderly, frail and vulnerable people who require high-quality care. However, it is also not possible to expect a magic wand—that is, the Government—to provide training overnight for everybody at once. Therefore, it is reasonable to find a way forward that provides a direction of travel that satisfies patients, the public, the professions and employers that the issue is being addressed as a matter of urgency within the economic situation in which we find ourselves.
I shall briefly address each item covered by the amendment. The Minister has indicated that Skills for Care and Skills for Health will be producing an assured training programme, prepared with professional inputs, that will, following consultation, be available for implementation in 2013. This will entitle successful candidates to be entered on the voluntary register if they so wish.
I am aware, and pleased, that the Minister has also agreed that work should proceed on reviewing the research on ratios of registered to unregistered personnel, and that the supervision of work delegated to registrants is vital. However, realistically, in some communities and hospital situations it is not possible for there to be close scrutiny of support workers’ performance. The recent report published by Which? clearly demonstrates neglect in the delivery of care to patients and in their safety. Clearly, the Government need a means of early identification of the failings in the delivery of care.
While the training programmes are being developed, perhaps we could ask, through the Minister, that registered nurses and midwives are reminded of their responsibility and accountability, that they have to assure themselves of the competences of individual support workers before delegating a task, and that, once a task has been delegated, it must be supervised. Where that proves impossible because of insufficient registered nurses and midwives, immediate action should be taken by a registered nurse to report to his or her manager and the employers should take action on the level of care that can be delivered in that situation. That will safeguard the safety and quality of care to patients.
I now turn to the second subsection of the proposed new clause. It is recommended that the next logical step would be to aim for the training of support workers to be mandatory. So far discussions on making the training of healthcare support workers mandatory has not found favour with Her Majesty’s Government. Many Peers indicated, on Report, the importance of all healthcare support workers receiving mandatory training and that it should be regulated. Although it is recognised that that could not be arrived at tomorrow, if Her Majesty’s Government could agree that the training programmes will be mandatory at a date to be determined for implementation, I am sure that the patients, the public and certainly the professions of nursing, midwifery and social care would be satisfied.
Subsection (3) of the proposed new clause requires the Secretary of State to develop a code of conduct for all employees whether they are entered on the register or just providing care. That includes the employees not just in the NHS hospitals but also in local authorities. That would provide clear guidance for employers as well as employees and should assist in ensuring that competences, where lacking, are made good by training modules or by withdrawing the person who does not have the skills or the competences. Without such controls of clearly defined competences being included for practising healthcare support workers and the correct delegation and supervision by registrants, it will be impossible to ensure the high-quality, safe, compassionate care that patients and clients deserve or indeed Her Majesty’s Government aim to provide. I hope that the Minister will feel able to provide a positive response to this request.
Subsection (4) requires Her Majesty’s Government to carry out a strategic review within three years, as the Minister undertook to do on Report, about whether statutory regulation of support workers is necessary in the light of progress with the proposed training programmes and the introduction of the voluntary register. Perhaps I may suggest that the review of the research on improving the ratios of registered nurses and midwives is also included in this review so that a holistic view can be gained of the future shape of the workforce required to deliver high-quality, safe and compassionate care, with the result of improved clinical outcomes that are cost-effective and of cost benefit. I beg to move.
Lord Patel
My Lords, on Report, I spoke strongly in support of the amendment in the name of my noble friend Lady Emerton. I thank the Minister for the many conversations that he has had with my noble friend and myself to try to resolve some of the issues. Like the noble Baroness, I am most appreciative of his readiness to meet and speak with us on many occasions.
We have about 450,000 healthcare support workers and some have had some training and therefore perform the tasks that they are given with fairly good competency. Others do not have any training and they might perform the tasks that they are given at variable levels. We also heard on Report from the noble Lord, Lord MacKenzie, and my noble friend Lady Emerton about the kind of tasks that healthcare support workers currently carry out. They range from simple nursing care or bathing or feeding duties to cannulisation and bladder catheterisation and even more invasive procedures than that. That should confirm to us that there is a need for some kind of standardised training programme that healthcare support workers must undertake so that their competences are assessed and so that they work to those competences. It is not fair that those healthcare support workers who have had some training and are competent to perform their duties have to work alongside others who have not had any training and, therefore, are lacking in competences.
On Report, one of the many things that the Minister agreed to take forward in relation to healthcare support workers, if I quote him correctly, was to try to establish assured voluntary registration, which the Council for Healthcare Regulatory Excellence will run. If we are to have any kind of register, surely ipso facto certain conditions must be satisfied before someone can go on to the register. Logically, that would suggest to me that there must be some form of training. If that is the case, why would we object to having training as a requirement for all new healthcare support workers? I well understand that it is not impossible, but very difficult and expensive, to try to train some 450,000 people who already carry out such tasks. That could be overcome by having a code of conduct imposed on employers; it would be their duty to ensure that whoever they employ has the competencies to do the tasks that they are asked to undertake. It would not be vastly expensive to get 450,000 people trained. Subsection (2) of the proposed new clause refers to “mandatory” training—I use the word “requirement”—for all new healthcare support workers from April 2003 before they go on the assured voluntary register.
I take a slightly different view about whether the register is voluntary or statutory. I know that the word “statutory” to all healthcare workers is important. I am registered by statute to be on the medical register but it is more important that the register has some meaning and that it works. If a voluntary register does not work, it is no good; if a statutory register does not work, it is no good. It is important that people who go on the register are trained and assessed as having those competences. Subsection (4) of the proposed new clause, to which the Minister agreed previously, requires that a review will be carried out for the benefit or otherwise of any kind of register that is established. I hope he will agree to that. I hope that the Minister will be able today to reassure my noble friend Lady Emerton.
I have been very touched by what my noble friend has said in the many conversations that she has had with me. To me, she typifies the attitude of a very caring nurse who is concerned about the poor quality of care seen in daily reports in newspapers; there was also a report yesterday from Which?, to which she alluded. That clearly affects her as a professional nurse. Therefore, I strongly support her amendment.
Baroness Emerton
I thank the noble Earl for that summary, and I thank noble Lords who have taken part in this short debate.
It seems as though we have been discussing this very real issue for months. We have spent the afternoon talking about risks and my concern has always been that the result of not providing training and support to support workers is a risk to patient care— and we will be taking a real risk if we have to wait the length of time proposed by the Minister. Work is going on at the moment in preparing the voluntary register, which will be ready in 2012, and I would have thought it would have been possible for the Government to say that from thereon they would expect candidates who are taken on to enter that training.
The public, patients and professions need an assurance that the risk at which we are placing patients is being addressed. The Minister has set out a timetable, but it is a very long timetable for patients who are receiving care today and tomorrow. They are at risk unless there is a registered nurse who is able to assess the competencies and support workers who are competent to deliver.
I appreciate what the noble Earl has said and the situation that we are in—I said in my speech that we have to be aware of the economic situation—and that we have to be assured that whatever we do is of benefit to patients and is cost-effective. However, I am not sure that we will be doing that by accepting the proposed timetable and I would like to test the opinion of the House.
Health and Social Care Bill
Baroness Emerton Excerpts(12 years, 2 months ago)
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Baroness Emerton
“Power to regulate health care support workers in England
(1) The Nursing and Midwifery Order 2001 (S.I. 2002/253) shall be amended to provide that all health care support workers in England shall be regulated in accordance with the terms of that order.
(2) For the purposes of subsection (1), a health care support worker shall be an individual whose work is routinely delegated to them by a registered nurse or midwife or has a qualification in health and social care at level one (or higher) of the Qualifications and Credit Framework, in England.”
Baroness Emerton
My Lords, I rise to speak to Amendment 240, tabled in my name, which relates to the mandatory training and statutory regulation of healthcare support workers. Before so doing, I thank the noble Earl, Lord Howe, and the noble Baroness, Lady Northover, for the time that they have given me in addressing this issue and for their very helpful responses.
The Bill is concerned with reorganising health service structures to improve the quality and safety of care and to improve the patient experience, building on the work of the noble Lord, Lord Darzi, in the last Government. The emphasis throughout the Bill is the role to be taken in the commissioning of services by general practitioners, but little attention has been paid to the other professions. Here I declare my interests as a retired nurse not on the Nursing and Midwifery Council register, a former tutor, manager and chair of the regulatory body for nurses, midwives and health visitors. I am also a lay member of the GMC, a former chairman of an NHS trust and a former trustee of the Kent Community Housing Trust.
I remind the House that nursing and midwifery form the largest individual professions in the NHS, currently with in excess of 600,000 names on the register. Moreover, some 400,000 members of the Royal College of Nursing support this amendment. It is concerned with the safe delivery of care to patients whether they are in hospital, in the community or within the NHS, local authority or independent sectors, along with nursing homes and charities.
I am grateful to all noble Lords who took part in the debates in Committee on the two amendments that I tabled then, the first of which asked the Government to produce guidelines on the ratios of registered to unregistered staff. I withdrew that amendment on the basis that further work would take place examining the research evidence. I am pleased to say that Ministers have taken this seriously and work is now in hand on the matter. I mention this as the ratio of nurses to unregistered staff is important in the points to which I now wish to draw the attention of noble Lords in making the case for healthcare support workers to be regulated against agreed standards and for this to be included in the Bill.
If this amendment is accepted, it would affect healthcare support workers—those who are limited to working under the direction of a registered nurse or midwife giving direct clinical care in hospitals, community settings and care homes. They would have accepted professional boundaries and would be entitled to practise, as set out on a list. There would be control of admission to and removal from the register. Professional standards of practice would be established, ensuring clarity for patients, the public and professionals, and individuals would be held accountable.
In a letter to me, the noble Earl said that the department is “unconvinced” that the regulation of support workers is necessary and that the Government’s policy is to set up a voluntary register. I am hoping to convince the Minister that having healthcare support workers subject to a voluntary register would not work satisfactorily in terms of protecting patients in the delivery of safe care. I pose two brief questions. First, what is the evidence to demonstrate that unsafe care is currently being delivered by healthcare support workers and the reasons for this? Secondly, is there evidence that will satisfy patients, the public and registered practitioners that the proposed voluntary register will ensure the safe delivery of care?
While a very large number of healthcare support workers deliver excellent care, most of them having received some basic training under adequate supervision and having gained experience, there is evidence that things can and do go dreadfully wrong, particularly where there is no appropriate training and poor supervision. Healthcare support workers are themselves calling for mandatory training and regulation.
We have only to refer to the most recent inquiries demonstrating unsatisfactory levels of care in Mid Staffordshire NHS Foundation Trust. The first report was very critical of healthcare support workers and the change in the staffing ratio of registered nurses to support workers. The second public inquiry is reporting on the confusion about supervision—not knowing who was in charge of care delivery. At Winterbourne View, a hospital delivering care to those with learning difficulties, charges were brought against support workers and guilty pleas have been made. The report published by the Local Government Ombudsman cited 10 instances of unacceptable care for the elderly. Moreover, prior to this there were inquiries at Maidstone and Tunbridge Wells NHS Trust and at Stoke Mandeville Hospital. While the failures in delivery of care were not due solely to the poor performance of healthcare support workers, that was found to be very largely a contributory cause. Failure in delivery of safe service care was due in the main to there being insufficient registered nurses to supervise the healthcare support workers and a lack of a set of standards for care training.
A survey of 2,500 support workers carried out by the Royal College of Nursing between the Committee and Report stages of this Bill demonstrated that tasks currently being undertaken by healthcare support workers call into question the safety of patient care. The list totals 56 examples, but I will illustrate just a few. Healthcare support workers were left in charge of wards and nursing homes, administration of drugs, including insulin and controlled drugs, the removal of wound drains and central lines, bladder scanning and washouts, catheterisations, especially in very ill patients, assessing patients pre-operatively and pre-chemotherapy treatment, changing tracheotomy tubes, inserting nasogastric tubes, giving feeds through those tubes, and suturing and plastering. These are just a few.
As recently as last Friday, I was chairing a national conference and was approached by a very senior nurse who told me of a family member, a young person of 17, who had applied for a job as a healthcare support worker. She received two days’ training. On the first day on the ward, she was allocated to do a bed bath. She was accompanied by another healthcare support worker to supervise her. She washed the patient’s face and hands and proceeded to complete the bath, but was told by the other healthcare assistant, “I only do hands and face here. We don’t bother to do anything else”. When questioned about the patient’s back and pressure areas, she was again told, “We do not do that here”. Very many of our workers are in that situation, both in the community and in hospitals.
Earl Howe
The noble Baroness, Lady Howarth, was, of course, quite right, because we have a mix of skills in so many settings. I did not share her view that, if I can put it this way, the skills of social workers were being belittled by the noble Baroness, Lady Emerton—not at all. She was, however, right to point out that the role of social workers can be just as critical for the well-being of patients and service users as the role of a healthcare assistant. We should not automatically think of these skills as medical skills; they are, in many cases, wider than that. We recognise that there are two distinct groups of workers here—that is the reason why we have asked Skills for Health and Skills for Care to work together to define standards of training. Despite the differences between the groups, there will be similarities; we want to tease out what those are and to define them accordingly. I hope that this is helpful. I hope, too, that the noble Baroness will be reassured and feel able to withdraw her amendment.
Baroness Emerton
My Lords, first, I thank all noble Lords who have participated in the debate this morning. It has highlighted and pinpointed one of the essential needs that must be addressed very quickly in terms of the future of the health service. The noble Lord, Lord Hunt, said that he thought that I had probably put down the amendment as it was worded in order to raise a debate. He was right—I was concerned to get a debate raised on the whole issue. It is unfortunate that despite the Bill’s title—the Health and Social Care Bill—social care has not been included yet. We know, however, that social care will come, and I have been a great supporter of mentioning support workers as we have gone through the various briefings. I take the point made by my noble friend Lady Howarth that social workers are just as important as the healthcare support workers. However, I had to draw a line somewhere as to the title of the debate and how we moved it forward, and I thank noble Lords for their contributions.
I have listened very carefully to what has been said, including by the noble Earl, Lord Howe. If I have heard correctly, I think that he has given a reassurance and a commitment about how things might emerge in the next few months in terms of developing the care standards for the training. He has also given an assurance that there will be a review later on, after the establishment of the training, as to whether statutory regulation would be possible or whether voluntary registration had been satisfactory. The noble Earl knows that we have been waiting a very long time for the examination of the regulation of healthcare support workers. I will take away what he has said and I will read very carefully in Hansard what has been said—a lot has been said in nearly two hours of debate—but, for today, I will withdraw the amendment.