Health and Social Care Bill
Lord MacKenzie of Culkein Excerpts(12 years, 2 months ago)
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Lord Turnberg
My name is attached to this amendment, which I believe is an extremely important one. I find myself in the somewhat unusual—indeed, unique—position of, for the first time, not being able to agree with the noble Lord, Lord Newton. We have had many debates in this Chamber in which the standards of care in our hospitals and nursing homes have been examined and, in too many places, found wanting. We have had many other reports showing the same thing. Many institutions and many care workers are outstanding but, as we know, there are too many places where patients are neglected and their basic needs not addressed.
Of course, all these failures cannot be put at the door of healthcare support workers. Where they occur, these failures are systemic and go right across the hospitals and homes. The employers, doctors, nurses and everyone in the institution should bear responsibility. However, all too often it is at the level of the healthcare support worker—who provides the basic care of feeding, washing, toileting and a host of other responsibilities and is often in closest contact with the patient—that we hear complaints from patients and their families. Healthcare support workers are at the end of the line and are too often left to themselves.
I fear that when we lost our SENs—our state-enrolled nurses, who did not need a university degree—in 2000, we lost a group of professionals who were trained and educated to do their job. If we are to regain the sense of professionalism and pride that my noble friend talked about that full registration would bring to a cohort of well trained and regulated young men and women, then we must move to full and proper registration. I do not believe that a voluntary register gives that degree of control. It certainly does not give sufficient recognition to the importance of the job. I hope that the Minister will agree.
Lord MacKenzie of Culkein
My Lords, I apologise to the House for not being here at the start of this amendment. Unfortunately, I had to seek the help of the health service this morning for a touch of bronchitis. I apologise particularly to the noble Baroness, Lady Emerton, for not being here on time.
I strongly support the amendment. I have spoken on this matter on each occasion that the call for statutory regulation has been debated in this Bill. I also referred to this issue in the debate on front-line nursing which we held last December.
The Government argue that voluntary registration is sufficient unto the day. I beg to differ strongly. As a nurse, I cannot agree that the present state of affairs should continue, and I do not think that I am a lone voice. The health committee in another place, the Nursing and Midwifery Council and all the staff organisations representing healthcare assistants all support statutory regulation.
History has a habit of repeating itself—wheels turn full circle. In the 1930s, financial pressures brought about huge increases in the numbers of support workers, or assistant nurses, as they were called. There was no provision then for regulation. It took the work of two committees—the Athlone Committee in 1937 and the Horder Committee in the early years of World War II —to lead to legislation which allowed for registered and regulated status for assistant nurses. We had state-enrolled assistant nurses as a consequence, and I think that it was in the early 1960s that the word “assistant” was removed from the title.
By the 1980s, the role of nurses on the first and second parts of the register was blurred. As a consequence, and as part of the move away from hospital-based training into higher education, the enrolled nurse training for first-level nurses was discontinued. It was always a mistake to leave that vacuum when the enrolled nurse training ended—a matter referred to by my noble friend Lord Turnberg.
The outcome is entirely predictable. That wheel has, indeed, turned full circle. We have had, again, huge increases in support staff; we have, again, financial stringency; and, as in the 1930s, there are now campaigns for proper regulation and training for those who assist nurses. However, the roles have been blurred this time not between the enrolled nurse and the registered nurse but between the healthcare assistant and the registered nurse. That is the very issue that led to the ending of enrolled nurse training, but this time there is no fall-back—there is no fail-safe for the patient—because there is no standardised training; there is no legal obligation in the Bill to require standardised quality training; and there is no obligation for registration, regulation, accountability and, not least, a code of conduct for support staff. The amendment in the name of the noble Baroness, Lady Emerton, will do much to resolve that issue. Most importantly, it is about patient safety. The amendment is specific—it is not about all support workers working in the hospital service or care homes; it is about those staff to whom are delegated what are, by any standards, nursing duties of registered nurses. It is not good enough for the Government to keep saying that voluntary registration is sufficient and that everything else is a matter for employers.
That is the present situation and it is far from satisfactory. I suggest that it will get worse in the future. We all know that the ratios between nurses and healthcare support workers are often worse than the generally accepted 60:40. The financial squeeze will certainly mean further changes—and not for the better. Voluntary registration does not work. For a long time, for example, clinical physiologists have been trying to make the case to the Government that voluntary registration has failed, and the coalition Government have turned their face. The leaving-it-to-the-employer approach will leave the patient at risk, and neither the registered nurse nor the healthcare support worker is protected in these situations if something goes wrong. Increasingly, the employer will be exposed as well, as there may well be more cases such as that of Mid Staffordshire as a consequence of financial pressures and getting skill mixes wrong—not least when these decisions are made by human resources people with little or no proper nursing input.
In my submission, the patients are not always clear about who is providing care for them. My recent six months as a patient in two teaching hospitals confirmed that—virtually everyone in a uniform was a nurse to most patients. That is not surprising. Healthcare assistants routinely carry out observation rounds; they carry out clinical procedures such as cannulation and catheterisation; they give injections; and they undertake venapuncture to take blood. That is just to name some of the procedures that they might carry out. Patients would be very surprised if they were told that the staff carrying out these clinical procedures were neither regulated nor registered.
Regulation and standardised quality of training does not, in itself, guarantee that matters will not sometimes go wrong. That can—and does—happen in all regulated professions. However, statutory regulation and registration is the best way forward to give better surety to patient safety. I strongly support these amendments.
Health: Neurological Conditions
Lord MacKenzie of Culkein Excerpts(12 years, 5 months ago)
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Lord MacKenzie of Culkein
My Lords, I, too, thank my noble friend Lord Dubs for securing this important and timely debate. It is important because there is a need for the difficulties encountered in getting high-quality care and support for persons with neurological conditions to be highlighted as much as possible; it is timely because of the present consideration in this House of the Health and Social Care Bill.
I want, if I may, to concentrate in the time available on motor neurone disease. When I practised as a nurse, I never came across this ghastly, fatal and rapidly progressing illness. Most general practitioners will perhaps see one or two cases in a working lifetime, and that is at least part of the problem when it comes to commissioning services. While there are some 5,000 people living with motor neurone disease in the United Kingdom at any one time, the condition is not common enough to appear on the radar in the face of the much more common conditions which we hear about all the time, such as stroke, cancer and cardiac conditions.
We had 60 new targets and outcomes announced yesterday, designed to assess quality of care. I have not yet had the opportunity to look at these indicators in detail, so I wonder whether there is one for long-term conditions. Will the Minister tell the House whether any of these indicators refer to the quality of care for someone living with motor neurone disease or other long-term conditions, and how such an indicator will assist in holding the NHS Commissioning Board to account? I note that the Secretary of State said that the department and Ministers would not interfere in how these quality outcomes were dealt with locally. Well, I wish that they would. I wish that something could be done more forcefully, better to ensure proper care and outcomes for patients with long-term conditions.
We dealt with this issue at the Committee stage of the Bill. It is the view of Ministers that the proposed framework provides for the potential for a change in the culture of the National Health Service in its approach to commissioning for long-term conditions. However, there is nothing in the Bill to ensure that cultural change. There are many promises and aspirations about the future, but they are peppered with words like “could do”, “may do” and “as they see fit”—not “will do” or “must do”.
The average survival for a person with MND is something like 14 months after diagnosis. As we know, it is rapidly progressing condition and has high need. I am advised by the Motor Neurone Disease Association that there can be as many as 18 different health and social care professionals providing care at any one time. I can provide testament to that. When my friend lived with and later died from this disease, he had very many professionals and carers involved in providing care, which was better in his case than many receive, but they still struggled to cope with the rapid deterioration and progression of the disease.
As well as high need, there is high cost with motor neurone disease. It is estimated that quality care can cost as much as £200,000 per annum. However, poor care can lead to crises and to unplanned hospital admissions, and costs can easily double. There is also some evidence, as I understand it, to the effect that the incidence of admissions to A&E of persons with MND is increasing. That is a worrying trend which should not be happening and is indicative of the patchy nature of care and financial pressures on social services in different parts of the country. The noble Baroness, Lady Finlay of Llandaff, told us last Wednesday about the lack of end-of-life care in Southampton; and the noble Baroness, Lady Hollins, has reiterated that this afternoon. It is not a case of poor care but a case of denial of access to end-of-life care.
I find it difficult to understand how present-day commissioners can sleep at night when few or no steps are taken to enable people with motor neurone disease to have the best quality of life and dignity in death. Dying badly is not something that should happen to anyone. Having seen the pressures on a family where care was reasonably good, I cannot for the life of me imagine how awful it must be where that care is denied. I fear that the funding pressures now facing the health and social services may mean that we see more Southamptons.
We need good practice to be built on. We need that good practice to be embedded in pathways and systems and we need it to be made sustainable rather than to rely on the individual clinical champions. Let us keep the patient out of hospital by avoiding crises and treatment that is not appropriate. Let us provide the support and the necessary adaptations to enable people with motor neurone disease to live at home with their families. That is good for the patient and it is cost effective.
As the noble Baroness, Lady Hollins, reminded us, the Government have recently announced palliative care pilots as part of their work on the palliative care funding review. I agree that it would make much sense for people with motor neurone disease to be included in the pilots, which should enable a tariff to be developed for these complex and demanding needs. Can the Minister say whether palliative care services for people with MND will be included? I hope he will confirm that.
I have mentioned services that can help people with motor neurone disease to live at home. When my friend was living with this disease, and despite the best efforts, none of the adaptations made to his home or equipment provided could keep pace with the disease progression. The noble Baroness, Lady Masham of Ilton, put it very well. These needs have to be met straightaway. In my friend’s case a particular example was wheelchairs. Quite early on, when he still had some mobility, it was decided that an electric wheelchair would be provided, but one did not appear until he had lost the use of his hands and could not use it. Had it been delivered on time he could have had some months of relative freedom. It is a story that I have heard all too often.
The noble Baroness, Lady Hollins, has also reminded us that the Motor Neurone Disease Association—to which I pay the greatest tribute for the work it does in supporting people affected by MND—has told us that many people have difficulty accessing wheelchairs appropriate to their needs and that, shockingly, as many as 500 people at any one time are waiting for wheelchairs, some for two years. That is totally unacceptable in a modern society. How many of us would like a relative or friend confined to their house—or, worse still, to an upstairs bedroom—for months? Yet that is not hyperbole; it is the reality for all too many.
This brings me back to the Health and Social Care Bill. As we know, the Motor Neurone Disease Association has developed a good partnership model with wheelchair services in pilot areas to ensure that people with MND have access to a wheelchair that is appropriate to their needs. The association would obviously like national expansion of this effective model for assessment and provision so that the present inequality of provision can be dealt with.
As the noble Baroness, Lady Hollins, said, the Health and Social Care Bill provides an opportunity, with the concept of “any qualified provider”, for the Motor Neurone Disease Association to expand its excellent work in providing a fast and efficient service. However, as we have heard in past debates, it is concerned that small third-sector organisations might be disadvantaged in the bidding process. Can the Minister confirm that small third-sector organisations, which are extremely important and valued in the provision of care, will not be disadvantaged against the larger organisations, which have all of the firepower when it comes to applying for “any qualified provider” status?
I hope that this debate today will contribute to the growing awareness of the need for joined-up care for people with long-term conditions. The Health and Social Care Bill fails, in my view, to provide for the integration of care between health and social services which, as my noble friend Lady Pitkeathley emphasised so well this afternoon, is really needed.
I fear for the transition stage. I think that I have seen something like 19 reorganisations of the health service, in one form or another, since I commenced nurse training in 1958. They have all caused disruption, and quite a few have caused disarray. I think that the Motor Neurone Disease Association is right when it expresses the view that some people will be diagnosed, experience the entire course of their illness and die before the NHS and social services get anything like back on an even keel. It is essential that high quality services are available throughout this time of transition. I share that hope and I look forward to what the Minister is going to say in response to this debate.
Nursing
Lord MacKenzie of Culkein Excerpts(12 years, 5 months ago)
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Lord MacKenzie of Culkein
My, Lords, we all owe a great debt of gratitude to the noble Baroness, Lady Emerton, for securing this important debate on front-line nursing today. It has been a very well informed debate. It is not very often that we have the opportunity to debate nursing in this House, so the debate is to be doubly welcomed. It comes at a time when the nursing profession is, to coin a phrase, getting it in the neck. As my noble friend Lady Warwick of Undercliffe said, not a week goes by but there are reports of poor care with a lot of armchair analysis of where it is all going wrong. There are justifiable concerns which have to be addressed, and I will come to them shortly.
Like the noble Baroness, Lady Emerton, I am a nurse who is no longer on the effective register, and I have not been for the past 10 years to so, but because of that I want to start from this side of the House by saying something in defence of the nursing profession. The vast majority of nurses, and midwives too, are good and safe practitioners. They provide good quality and safe care. They are highly skilled. They are involved in research and all sorts of things that could have been only dreamt of in my early days as a nurse. Good work does not get publicity. The noble Baroness, Lady Jolly, reminded us of the good work done by Macmillan nurses and hospice nurses, and the noble Baroness, Lady Masham, and the noble Lord, Lord Ribeiro, referred to nurses who join the military reserves, spend six months in Camp Bastion, then come back and continue their remarkable work in the National Health Service. Good work is done by specialist nurses, such as stroke nurses or community psychiatric nurses, to highlight just a very few. Good things do not get publicity; bad things do. The image of the nursing profession is suffering as a result of recent publicity, some of it rather damning, about the quality of care in a number of settings.
In my experience, morale has its ups and downs, and now it is on the way down but at least until now the image of nursing had always been good. Morale is now being hit from a number of areas including the growing public perception that nurses are not capable of compassionate care, the two-year pay freeze and pension issue, the downgrading of posts and the actual and forecast staffing reductions coming from the Royal College of Nursing and UNISON. As we have heard today, that is not just hyperbole from staff organisations. The noble Lord, Lord Patel, told us stories about special care baby units and the number of neonatal nurses who are being downgraded while in post. We are getting the same story from the Multiple Sclerosis Society that a significant number of posts are being cut.
It became really too much when a leader in last week’s Sunday Times said:
“One reason for the government’s tough austerity programme is that … Labour poured more money into the National Heath Service … and the number of nurses increased by a fifth”.
That is going too far. Poor morale is not conducive to happy nurses, and no Government can ignore it for very long. I think a match may have been put to a slow-burning fuse with the prospect of even heavier cuts, 1 per cent pay maxima and possibly different salaries for nurses doing the same job, for example, in Stockton-on-Tees and in Guildford. Bad morale has an effect on staff. It cannot be overlooked, but neither can or should it be used to justify bad delivery of nursing care. I hope that we can get some broad measure of agreement on the way forward, which means dealing with some of the reasons for the apparent decline in some aspects of care.
The report of the Prime Minister's commission on front-line nursing, set up by my right honourable friend Gordon Brown, has much to commend it. The noble Baroness, Lady Emerton, was, as she reminded us, a commissioner. The recommendations of that commission, if implemented, point the way forward on many of the issues that need to be addressed for the future. The present Government welcomed the report. They say that it does not go far enough but, at the same time, they say that it has to be looked at in the light of the present economic climate. That might be a contradictory position.
Staffing levels are always an issue in nursing. We heard about them yesterday in the debate on mandated levels and ratios, and we know from research that inappropriate staffing leads to poorer care and higher mortality. In response to amendments yesterday, the Minister told us about the safeguards that will be in place, but most of them are already in place yet have not prevented the problems, for example, in Mid Staffordshire, and when the CQC gets involved, it is, as was highlighted yesterday, usually too late.
There is much mythology about the so-called good old days. The press are forever hankering after matron, but know nothing about the science and art of nursing. What is not a myth is the fact that basic or essential care was better. I speak as a fascinated observer and recipient during a recent six months’ hospitalisation. I should have been in for one night, but ended up staying for six months. My experience was that most technical skills were excellent, although staffing levels and ratios outside intensive care and high dependency were not always good enough. Essential care was not always as good as it could or should have been. The care that used to be delivered by enrolled nurses, student nurses and pupil nurses is now delegated to some 303,000, I understand, healthcare assistants or support workers who fulfil many different nursing and midwifery roles. I am told that there are some 120 different job titles for support workers throughout the National Health Service. If that is true, find it astonishing. As was said yesterday, there is too much variation in the quantity and quality of training available for support workers. That needs to be improved and to be done to a national standard agreed with stakeholders. Scotland has already done this, and Wales and Northern Ireland are looking to follow.
Much of the care that is delegated to healthcare assistants is hydration, nutrition, pressure area care, intimate care, oral hygiene and keeping the patient clean and dry. We used to call that nursing care but, to my regret, it is often now dismissed as social care. It is nothing else but essential nursing care, and if it is not done, and done properly, then we have lost sight of what we are about as a profession. Healthcare assistants increasingly do more than essential care. They do temperature, pulse, respiration and oximetry observations. In the community, they are dressing leg ulcers and undertaking catheterisations and tube feeding, which were once the sole prerogative of the district nurse. I understand that healthcare assistants can, in some hospitals, undertake procedures such as cannulation. I wonder whether patients know that the person putting a needle into their vein is unregulated and not professionally accountable. I suspect they would be surprised.
Can we get rid of the confusing titles? Patients are entitled to know who is looking after them. The noble Baronesses, Lady Masham and Lady Browning, and my noble friend Lord Young mentioned uniforms. They are confusing. Patients have no idea who is looking after them. The whole of the profession is suffering because the basics are not always being attended to. This is, I am convinced, due to incorrect staffing levels and training, education and organisational cultural issues. It is also to do with societal attitudes to the elderly, which is not peculiar to the National Health Service. The National Health Service cannot cure society's ills, but it needs to get a grip and sort this matter out internally.
There are more changes to come. Nursing in England is to become a wholly degree-based profession, which is right. But perhaps I may pick up on the point made by my noble friend Lord Young that there needs to be a wider entry gate. There is always the fear that when a profession becomes wholly degree-based, it cuts out the possibility of a number of people who would make excellent nurses getting entry to that profession.
Good selection of potential students is essential. Recently, we have heard quite a bit about nurses not being fit to practice when they emerge from universities. I do not know whether enough nursing input goes into that selection but, if not, it should do. We also need to deal with clinical practice and relate it to theoretical content, and we need to get it right. My noble friend Lord Hunt of Kings Heath has spoken at length on this point and I agree with him entirely. I do not think that there is anything wrong with a practice-based model and I hope that those discussions are not at an end.
Protection of the public should be effective, all the more so given the cost-driven trend for employers to substitute trained nurses with support workers. That brings me back to regulation, at least of those who are delegated duties by trained nurses. The Nursing and Midwifery Council, the Royal College of Nursing, UNISON, the Queen’s Nursing Institute, the health committee in another place and, not least, healthcare assistants themselves want statutory regulation. The Government do not agree. They want assured voluntary registration. Some regard this as a small step in the right direction. It is small step but we do not think that it goes far enough. However, we will come back to that debate in the near future under the Health and Social Care Act.
Perhaps I may return to the Prime Minister’s commission on front-line care. I hope that the Minister will give us some detail on what the Government plan to do with each of the recommendations. I appreciate that that is a tall order, so perhaps he could write to us. There are four very important first principles. On the pledge for nurses and midwives, my noble friend Lord Young spoke about the Hippocratic oath and having an equivalent, which could be developed.
We have heard a lot in this debate about the responsibility of senior nurses. I agree entirely that they need to be given back the authority that they had. On corporate responsibility, as we have heard, recently Sir David Nicholson told a conference of senior NHS staff that many of its employers had no idea of how many nurses they have in the hospital or on a ward at any one time. A hobbyhorse of mine is the return of the ward sister. That responsibility must be restored and properly defined. Like the noble Baroness, Lady Emerton, I am passionate about nursing. I look forward to what the Minister has to say. Again, I thank the noble Baroness for giving us the opportunity for this debate.
Health and Social Care Bill
Lord MacKenzie of Culkein Excerpts(12 years, 5 months ago)
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Lord Walton of Detchant
My Lords, I, too, wish to support the principles underlying the amendment proposed by my noble friend Lady Emerton. However, one concern I have particularly relates to paragraph (4) of Amendment 139. Concerns have been expressed in many quarters over the past two years about the variable quality of the health care assistants employed in many of our hospitals. Some of them are absolutely excellent, but some of them—particularly in certain care homes—have had very little training and there is no process at the moment by which such care assistants can be registered; nor is there any formal requirement of a specific training or educational programme for these individuals. The time is approaching when there must be minimum standards of education and training laid down for such people. I trust that, in relation to what is said in paragraph (4), we can have an assurance from the Minister that this is an issue that the Government will consider.
As the noble Lord, Lord Alderdice, said, the same problems arise in relation to psychologists. Clinical psychologists have a formal training programme but not all psychotherapists, who do not hold a medical qualification—they do not have any such programme, although many of them make an outstanding contribution. The regulation of psychologists has been discussed for several years but little progress has been made. Can the Minister tell us whether that is still under consideration?
My final point relates to the fact that the regulation and registration of many of the other professions working in the NHS, in hospitals and the community—occupational therapists, physiotherapists and others—of course comes under the Health Professions Council. This is a Health and Social Care Bill. Only two years ago, a statutory authority for the registration and regulation of social workers was created, the General Social Care Council, and that body is in existence. I want to ask the Minister: is it proposed, as I believe is the case, that the Government are going to bring that body within the ambit of the Health Professions Council, or are they going to make it subject to the oversight of the council for regulatory excellence? That is a matter upon which the Committee needs to be reassured.
Lord MacKenzie of Culkein
My Lords, my name is down on this group of amendments. I very much agree with what the noble Baroness, Lady Murphy, said about the situation in California, because the importance of being attached to the mandated levels of staff is self-evident from that.
This issue has been around for as long as I can remember. It was around when I was practising a long time ago. It was around when as a leader of a predominantly nursing trade union I had discussions with health departments in the days when there was perhaps more famine than feast in nursing levels. However, Ministers and Secretaries of State never seem to want to make a real effort to engage with stakeholders on this difficult issue.
There have been a number of efforts over the years, a number of tools used to measure patient dependency to staffing levels and to skill mix ratios as an adjunct to professional judgment. Some of these were useful, some—particularly imports from abroad—were much less so. I can remember one of them, an import from the USA, probably at some considerable expense, which was known by the particularly ugly acronym of GRASP. That stood for, if I remember correctly, “the Grace Reynolds Application and Study of PETO”—I am never quite sure who or what “PETO” was. It sought to measure direct care activities and interventions, so that the correct nursing staff levels were always available. In reality, that tool caused uproar, because far too often it managed to show that wards were overstaffed when the reality was that staff were struggling.
There have been other, more useful, tools and systems, but some of them used up a lot of nursing time on paperwork, and more often than not, nurse managers had to retreat in the face of financial pressures. They have to retreat in the face of financial pressures because there is no mandate to defend a professional judgment in the face of these financial pressures. There is no agreed ratio of nurses to numbers of patients, and no agreed ratio of trained nurses to healthcare assistants.
That is the issue addressed in these amendments, and if the wording is defective, as the noble Lord, Lord Alderdice, is suggesting, I really want to concentrate on nursing here, and if need be we can bring that back at Report. We cannot escape the fact that the correct levels of staffing, with the correct skill mix ratios, are vital for the proper level of care, whether that is in acute wards, in primary care or in care homes.
Healthcare is complex, and I am not suggesting for one moment that the correct staffing level will in itself always guarantee good technical and good compassionate nursing care. However, it is a sine qua non that getting staffing and skill-mix ratios wrong means that it is difficult, if not impossible, for nurses and midwives to deliver anything like the high quality care that they want to deliver. We know that outcomes and mortality are affected, and I associate myself with the figures given by the noble Baroness, Lady Emerton.
Given the fears about financial pressures relating to future reductions in clinical posts—and certainly in relation to frontline nursing posts—it is no good for the Government to express expectations that quality is going to be improved or maintained without taking steps to ensure that their expectations are translated into reality and into practice. There will be more problems to come, as in the recent CQC report, as evidenced in the inquiries into the Mid Staffordshire NHS Foundation Trust, unless the steps proposed in these two amendments, or something like them, are taken on board.
We all want the best for patients and these amendments will go some of the way to ensuring that that will be the reality for the future. A mandated guarantee of safe staffing levels and ratios is essential for one principal reason and one principal reason only—patient safety and outcomes. These amendments have my wholehearted support and I look forward to the Minister’s response.
Lord Hunt of Kings Heath
My Lords, perhaps I could intervene to say that I echo everything that my noble friend said about the work of the clusters. They are covering, in my case, some 1.3 million and clearly are trying to get to grips with the strategic leadership that is required on the whole issue of reconfiguration of bed numbers and all the things that have been put off for so long. My understanding is that they go on as local field offices of the NHS Commissioning Board. That is the whole point. The question that then comes back, and where I am completely puzzled, is where on earth is GP commissioning in this? It is abundantly clear that the clinical commissioning groups are going to have very little influence. When you come to the issue of the individual GP, which was what this was all about, it is very hard to see what on earth they will be doing in terms of commissioning.
Lord MacKenzie of Culkein
May I intervene briefly, as I have my name down to Amendment 168? This has been a very important debate, and I want to return briefly to the issue of collaboration. Whatever the outcomes in size of the clinical commissioning groups, there will be a need for joint commissioning. I refer particularly, as the noble Baroness, Lady Finlay, has said, to some of the rare conditions, such as many of the neurological conditions, which will require a population, as I understand it, of some 250,000. For motor neurone disease this will be a population of some 500,000. It is vital that we have in the Bill something about joint commissioning for long-term illnesses. We will come back to that issue in a later group of amendments, but I want to emphasise its importance.
Baroness Tonge
My Lords, before the Minister gets up, I would like to ask him a very simple question. Noble Lords will have all realised by now that I have no faith in this Bill whatever, and never have had. I think it is totally unnecessary in the current economic circumstances, let alone other circumstances. Will the Minister tell us honestly what the reason was for clinical commissioning groups? Why could we not have kept the PCTs in whatever clusters they have formed together, and put clinicians, GPs, dentists and nurses into those groups to lead the commissioning process? Why did we have to have this massive upheaval to achieve what, according to what most of the speakers here tonight think, is not going to be achieved anyway, as the GPs will not have much input? Perhaps he could explain.
Health: Flu Vaccine Research
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Earl Howe
My Lords, the difficulty with advertising is that there is no evidence either way as to whether an advertising campaign has an impact on vaccine uptake, although there is no doubt that it has an impact on vaccine awareness. Without a marketing campaign last year, it was notable that the flu vaccine uptake was very similar to that achieved in previous years. We believe that the best way to access those who are at risk is through GPs. We know that from surveys that ask patients what has prompted them to get vaccination.
Lord MacKenzie of Culkein
My Lords, has the Minister seen reports in the nursing press that student nurses are being denied the influenza vaccine, despite advice to the contrary from the Chief Medical Officer? Can he comment on that and see whether something can be done about it?
Earl Howe
My Lords, although student nurses are not technically employees, as the noble Lord will know, they will be working for a particular NHS trust, with that trust’s patients, and it is therefore the trust’s responsibility to consider the safety of the student nurse and indeed the patients that they care for. If student nurses are going to be carrying out front-line work, particularly with vulnerable patients, then the trust should follow the advice we have issued on healthcare workers generally.
NHS: Hinchingbrooke Hospital
Lord MacKenzie of Culkein Excerpts(12 years, 6 months ago)
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Lord MacKenzie of Culkein
I understood the chief executive officer of Circle Health Ltd to say on television this morning that his organisation was a social enterprise on the Waitrose model. My understanding of Waitrose is that all employees are partners and that profits are either paid back to the partners or reinvested in the company. Is that the situation with Circle Health Ltd?
Health and Social Care Bill
Lord MacKenzie of Culkein Excerpts(12 years, 6 months ago)
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Baroness Wheeler
My Lords, I am pleased to move this important amendment, supported by my noble friends Lady Thornton and Lord Hunt. The amendment would provide some much needed morale and security at a time of great upheaval for NHS staff. In turn, it would reassure patients that the morale of those treating or caring for them will not impact on the quality of care they receive. Let us just imagine how NHS staff must be feeling now, no matter how dedicated or determined they are to carry on providing the best care possible. There is the Nicholson challenge to implement £20 billion-worth of savings, which they know will seriously impact on patient care, they are facing huge disruption to services and patient care as primary care trusts and strategic health authorities are abolished under the enormous upheaval of reorganisation, and there is massive uncertainty about the future bargaining arrangements for their pay and conditions.
The amendment calls on the Government to commit to the continuation of national determination of pay and national collective bargaining for terms and conditions for NHS staff under the reorganised NHS, leaving employers and trade unions nationally to agree what local flexibilities should operate. The Government have so far failed to acknowledge the need to retain national workforce structures for terms and conditions, pay and bargaining. The Bill prescribes nothing on the pay systems that clinical commissioning groups should adopt, giving them greater leeway to break away from the existing long-established and well-tested pay systems for NHS staff.
Agenda for Change is the single, national pay system in operation for the NHS and applies directly to all staff, excluding doctors, dentists and some very senior managers. It is well established, much respected by employers and staff and delivers equality-proof pay and grading schemes. However, the Liberating the NHS White Paper threatened the viability of a stable, national collective agreement, potentially undermining the NHS pay review body, which makes recommendations on the remuneration of all staff paid under Agenda for Change and employed in the NHS. The current Bill applies only to England, but the implications for national pay determination across the UK are significant.
We know that most staff do not work in the NHS to get rich, despite the constant, distorted picture in some parts of the media about the levels of public sector pay and pensions. Nurses’ pay starts from £21,000 a year and healthcare assistants from as little as £14,000 a year. The average public service pension is around £7,800 a year, but the average pension for a woman working in the NHS is only around £3,500 a year. If staff do not work for the NHS to get rich, what do they value? Job security is no longer the public sector staple employment motivator that it was: 13,000 redundancies have resulted from the current reorganisation. A recent survey by the Royal College of Nursing showed that an estimated 15,000 nurses and healthcare assistants expect to be made redundant in the next 12 months. Staff are not able to value job security any longer, but they do value fairness. Agenda for Change has delivered that, as well as equal pay.
In the uncertain environment caused by the reforms, having some guarantee about access to a fair, national pay system would at least provide an element of security. If, in the future, foundation trusts, with the heavy financial pressures they will face, start to abandon established pay rates and conditions, we fear that this will lead to the rapid downward spiralling of pay for staff, which will be particularly hard in these economic times. Staff morale and motivation are already suffering, and local pay bargaining would make it harder for the NHS to recruit and retain the best available staff, so in turn affecting patient service. Undermining staff pay and moving to local pay bargaining would also have a detrimental impact on patients. We must have an equitable spread of doctors, nurses and other professionals across the country. If local pay bargaining leads to many health staff moving away from a particular area, we could see the quality of service reduced there or patients having to wait longer because vacancies have not been filled. Agenda for Change is generally considered across the NHS to be a vast improvement on the previous fragmented and complex arrangements. It is seen as providing a firm basis for taking forward important, substantive issues, particularly equal pay, new ways of working and workforce reprofiling.
The amendment also explicitly refers to public health staff, because this is one of the major concerns for the NHS public health workforce, who continue to operate in limbo, unsure of exactly who will be employing them and on what pay, terms and conditions. The Government have promised a detailed public health workforce strategy in the autumn to support effective transition to the new system. When is the strategy to be published and what will be the consultation arrangements for all stakeholders? All we know now is that the directors of public health will transfer to local authorities, but precious little else is known yet about the arrangements for the remaining public health workforce, a factor highlighted by the House of Commons Health Committee last week. The committee stressed that,
“uncertainty has inevitably been created by the transition to new structures; this is undermining morale and causing people with valuable skills to leave the profession. Uncertainty around staffing issues must be resolved as quickly as possible. It is also important that the public health specialty is fully integrated into the Government's forthcoming proposals for healthcare workforce planning, education and training”.
The amendment would give the Government a chance to provide some much needed solace for public health staff by committing that they should be covered by the same pay system as other health workers. It would also give hope and reassurance to all NHS staff about their future pay bargaining arrangements. I urge the Minister to respond positively.
Lord MacKenzie of Culkein
My Lords, I rise to support Amendment 45 and to follow on from my noble friend Lady Wheeler. I have spent quite a lot of my working life negotiating pay and conditions for staff in the National Health Service. I sat on four NHS Whitley councils for a very long time—one of them for 21 years. As a nurse, I was privileged to lead negotiations on behalf of Britain’s nurses and midwives for quite a few years as chairman of the staff side of the Nursing and Midwifery Staffs Negotiating Council. So I know a little about the subject of this amendment and the possible consequences of any breakdown in national pay and conditions of service for National Health Service staff.
We have had nationally agreed pay and conditions ever since the inception of the National Health Service, with occasional attempts to break this down, particularly in the late 1980s. The Government of the day thought better of it and backed away. The old Whitley system stood the National Health Service in good stead for many years, but it was far from perfect and there was not always peace and harmony. There were problems in some years, going back, for example, to 1972 for ancillary staff, 1974 particularly for nurses and 1982 for most staff groups. The most recent that lingers in my memory was the ambulance dispute, which I think was in 1990.
Not all staff unions in 1983 agreed that the Government should set up a pay review body for nurses and midwives and professions allied to medicine. However, it was in my view an entirely sensible move, which by and large took a lot of heat out of relations between management and staff organisations for these two groups of staff. Why was the pay review body the right solution? The review body was independent and the staff unions were forced to undertake very detailed research into their pay claims. We used to spend many months getting that evidence right. The management side and government put in evidence as well. The Office of Manpower Economics, which provides the secretariat to the review body to this day, also carried out its own research. The review body took oral evidence from all of the parties. I led that for a number of years on behalf of the staff side. The members of the review body—academics and professionals—put us through the hoops, and any half-baked evidence would have been very quickly exposed. There was no question of any staff side taking inflation, doubling it and—metaphorically at least—banging the table. That clearly would not work.
Earl Howe
They will be employed by local authorities. It is too soon to say to the noble Lord what the pay grade of those people will be, but clearly they will be very senior officers within the local authority. Yes, strictly speaking, if there is freedom to set pay locally, there could be some variations around the country, but I would envisage that the pay grade of directors of public health will gravitate towards a certain figure, whatever that may be.
Lord MacKenzie of Culkein
The Minister spoke about the value of the pay review body being independent, but I was not clear whether he saw a future for that body. Could he clarify that first?
Earl Howe
My Lords, we value the pay review bodies, and there are no plans to disturb them at the moment. I sought to indicate that we continue to look at how pay arrangements are best structured. The pay review bodies do an extremely valuable job at present, as they have done for many years.