Queen’s Speech

Lord Young of Norwood Green Excerpts

Tuesday 22nd October 2019 Lords Chamber

[Lord Young of Norwood Green (Lab)]

My Lords, I declare an interest as an apprenticeship ambassador and an ex-apprentice. Noble Lords can guess from that introduction that I shall focus on apprenticeships in my contribution.

I start from the premise that I want the apprenticeship levy to succeed. I was a bit puzzled about the Government’s commitment to it when I looked through the list of Ministers, only to find that we no longer have a Minister for Apprenticeships. I do not know whether that is intended to signal a lack of interest or is just the accidental result of a reshuffle, but if we look at the list of government Ministers—I can see a puzzled response—we will not find a designated Minister with that responsibility. Of course, the Secretary of State has the ultimate responsibility, but that is not quite the same as when we had a Minister for Apprenticeships.

The Government had a target of 3 million apprentices during the life of this Parliament. I remember many of us saying that they should forget the target and focus not on the quantity but on the quality of apprenticeships. You need to convince people—potential apprentices, their parents and their teachers—that this is a worthwhile career path. It seems that the Government are beginning to realise, first, that they will not reach that target, and, secondly, that we were right when we said that they should focus on quality.

I started to look at some of the statistics, and the most worrying was for the starts at level 2. Why does that matter? Level 2 apprentices are often the young people who will not go on to an academic education. They are the young people who, perhaps, have a more practical bent at this point in their lives and who—I hope—we want to prevent becoming NEETs: not in employment, education or training. They really are an important group. I listened carefully to what the noble Baroness, Lady Garden, said, and I agree with many of her points. If you look at those statistics, it really is quite worrying. We started in 2016, before the levy, with 260,000 and we are now down to 142,000. That is a worrying loss.

I discussed the next area of statistics that I am concerned about with the Government. I told them that if they wanted the apprenticeship levy to succeed, they had to ensure that they moved the needle on the dial on the number of small and medium-sized enterprises involved. Again, I failed significantly. It is really hard to get statistics, but the House of Lords Library gave me this one: we started, again in 2016, with 473,761, and by the time we reached 2019, we were down to 170,325. That is a really worrying drop in the number of apprentices employed by SMEs.

I acknowledge that the Government have listened to large employers who said, “We’re not managing to spend our levy money; we would like to send more of it to our supply-chain SMEs”. The Government increased the amount to 25%. Did that solve the problem? No, because, as companies tell me, you cannot just throw money at these SMEs in their supply chains; they have to be managed. One thing I want to say to the Minister—I do not expect a reply today—is that some of that levy money ought to be used in the management of these supply chain SMEs, in admin costs, for example. If the Government really want to increase the number of SMEs employing apprentices, I recommend that they look at what are known as group training associations, which deal with things such as admin and basic skills.

I was really interested in the comments of the noble Baroness, Lady Featherstone, who is in her place, about the 2012 Olympics. A major theme in that unforgettable opening ceremony was the NHS. I could not help thinking that we have 40,000 nurse vacancies at the moment. It was a really smart decision by the Government to charge potential nurses for their degree programmes. Why would we do that when we are desperate to fill those skilled vacancies? That has had an unfortunate impact on morale in the National Health Service. The Government ought to scrap the charges for nursing degrees. We surely want to encourage a vocational route and encourage healthcare assistants who have the potential to become nurses, which many have.

I am coming to the end of my allotted time, so I will be brief. On average, employers claim only 50% of their levy money. They say to me, “What will happen to the unclaimed levy?” Sending it back to the Treasury does not seem a very smart solution to me.

Queen’s Speech

Lord Young of Norwood Green Excerpts

Thursday 29th June 2017 Lords Chamber

[Lord Young of Norwood Green (Lab)]

My Lords, I welcome some of what the Minister said about education and skills, which are the areas on which I wish to focus. I congratulate my noble friend Lady Sherlock, who is no longer in her place, on her outstanding contribution. She covered the waterfront, and I do not intend to try to match her.

I declare an interest as the recently elected chair of the board of governors of my local primary school. If I make one plea, which echoes what many noble Lords have said, it is about the importance of primary education. We know that if we get it wrong there, there is a cost of dealing with that. Sometimes I wonder whether we realise the size of the challenge that schools face. I can talk only about my school. There is a modest number of languages—about 30—where English is the second language. A significant number of children enter the nursery school not toilet-trained and with very few social skills. The school almost becomes a surrogate parent in those early years and has to overcome those difficulties. My school is doing exceedingly well, and I pay tribute to it. It is now in the top 3%, thanks to the dynamic leadership and the quality of the staff. I hope that we recognise the importance of that.

I want to focus on the need for a more holistic assessment of where we are spending money in education. I could not help but look at the staggering amount of money that is now outstanding in student loan debt: £89.3 billion. New lending and interest added outweighs the repayments being made by those borrowers who are now liable to repay. If I thought that all that investment was focused and if any objective cost-benefit analysis showed that we are getting value for money and that the spending is where it needs to be, perhaps we should not worry, but I query whether it is. Students face leaving university with a debt of £40,000 to £50,000, assuming they complete the course. A worrying article appeared in today’s Times, headlined:

“One in ten students from poor households drops out after first year”.

It said:

“Almost one in ten students from disadvantaged backgrounds is dropping out of university after the first year. Official data showed that 8.8 per cent of young, full-time undergraduates from poorer homes did not return for their second year of study in 2014-15, up from 8.2 per cent the year before … For middle-class students, the figure was less than 5 per cent. More disadvantaged young people are in higher education than ever before but the dropout rate has risen for the second year in a row”.


You cannot help wondering whether university education was appropriate for all those students. That is the first question that we need to be asking. In many cases, it is not. It is the only career path they are encouraged into because secondary schools have the incentive to get students into their sixth form, whereas they should be pointed towards the vocational path, which I will come to in a bit.

A further comment on university education is that here we are, in 2017, and yet we still focus mainly on three-year degrees. But does it really? Are we getting value for money? Most university students I speak to do not give year 1 much of a tick, other than to say that they enjoyed it—whether they learned much is another matter.

I focus briefly on further education. I welcome the £0.5 billion, but I am not so sure that that will be enough to deal with the challenge of what is needed in vocational education. T-levels are a good idea, and we certainly need to up the standard and status of vocational education. Unfortunately, it is still seen by many as a second-class career path.

There is a need for high-level apprenticeships in STEM areas. The Royal Academy of Engineering estimates that 830,000 more science, engineering and technology technicians will be needed by 2020 to meet the industrial demand. The latest apprenticeships statistics show that we are nowhere near that figure.

To conclude on the subject that arouses my greatest interest, I am not particularly worried that the Government are unlikely to meet their target of 3 million apprenticeships because I still think the focus should be on quality rather than quantity. If you look at the analysis of those apprenticeships, you will see that the vast majority are in care and hospitality. It is not that there is not a need in those areas, but we also need apprenticeships in the STEM areas, such as construction and engineering.

I have two final questions for the Minister—he has only 100 or 200 to answer already in his right of reply. Are we getting an impact from the apprenticeship levy? Can we see the needle on the dial for the number of small and medium-sized enterprises that are actually employing apprentices? In my view, if that number is not increasing, the levy has failed.

I have one final point. I was interested in all the efforts we will make on new technology, et cetera, but I noticed that in all the points made by the noble Lord, Lord Ashton, there was no reference to cybersecurity, which rather baffled me. Apart from the vested interest we have in this House, having suffered an attack ourselves, there were more serious attacks on the National Health Service. We know that the whole of this country needs to up its game. I would welcome some comment on that.

Health Service Medical Supplies (Costs) Bill

Lord Young of Norwood Green Excerpts

Committee: 2nd sitting (Hansard): House of Lords
Wednesday 25th January 2017 Grand Committee

[Baroness Walmsley (LD)]

My Lords, the noble Lord, Lord Warner, is right that we need to have a trigger mechanism. This is gold-plating, and not very effective gold-plating. As the noble Baroness, Lady Finlay, just said, it will produce an absolute mass of information. The question is how to find, among that mass of information, situations where there is malpractice, abuse or unwarranted price rises. It is the same sort of argument as we had when the police wanted to collect everybody’s internet information. Really, it is like looking for a needle in a haystack. It is much better to have it targeted, where there is a reason to believe that there is something going on.

How will the department identify from this mass of information those situations that it needs to investigate further? Will it apply some sort of algorithm to the information at any point along the production or distribution line when there is an increase of more than a certain percentage or a certain percentage related to the average—or what? How is it going to be done? These companies have quite enough to tackle with Brexit coming along the track and do not need a further burden such as this.

[Lord Young of Norwood Green (Lab)]

I am not an expert in this area, but I am puzzled. If it is that difficult to identify, how come the Times managed it in its expose? It did not seem very difficult or complex. The Times found drugs that had come out of patent and were available on a generic basis and for which the company that bought the patent increased the cost by staggering amounts. You do not have to be Sherlock Holmes to alight upon that. I do not know which way to go on this debate. My noble friend worries about fishing expeditions, and he is right, but I am even more worried about the NHS being ripped off for inordinate amounts of money by people whose corporate responsibility polices omit the word “ethics”. I asked once before why none of the current audit processes inside the health service exposed this until the Times brought it to public attention. There may be a mass of information, but I would have thought that these things could quite easily be identified. I may be wrong because, as I said, I am not an expert in this very complex area, but those points need to be answered. The problem was identified. We have this Bill because we know that the current system is not working. Even though people in the various systems in the NHS were reporting their concerns, no action was taken for quite a long time. It certainly justifies the legislation. The Delegated Powers Committee expressed its concerns about whether the legislation is right, and I do not profess to be qualified to rule on that, but my major concern is about the ability of some companies to rip off the NHS.

[Lord Hunt of Kings Heath]

My Lords, my noble friend is right because he goes to the heart of the argument about this Bill. I think we have all said that we support the core aim, which is to deal with branded products becoming generics and the issues that were identified. The question is whether the Bill is a proportionate response to that and what impact it will have on future investment in this country.

I have been wracking my brains to puzzle out why this was first legislated for in 1977. My noble friend will remember that that was the time of the prices and incomes policy. Lady Williams of Crosby and my esteemed noble friend Lord Hattersley were Secretaries of State for Prices and Consumer Protection. I would not be at all surprised if it had something to do with that. I have to say that it was not altogether successful as a policy, and I am not sure that it is a great precedent for the Minister to rely on now. Certainly, in 1979 the electorate did not think that it was a very successful policy, that is for sure.

The only point I want to put to the Minister is this: I think there is a consensus in the Committee that there needs to be some trigger mechanism. We have had elements of that. The noble Lord, Lord Lansley, proposed an amendment that included appeals. He suggested what would trigger action, which was very helpful. In his amendment, my noble friend suggested another approach. The Delegated Powers Committee is concerned about the general terms of this clause. It said:

“We consider the general power to be inappropriate unless the Minister is able to explain why it is not feasible to specify the further bodies to whom information may be disclosed on the face of the Bill, and why it is not feasible to limit the kinds of bodies to whom disclosure may be made”.


That picks up the point raised by the noble Lord, Lord Lansley, and I agree with him about NHS bodies,

The question is this. The only satisfactory safeguards will be in the Bill. This House has no influence on regulations. The Minister will know that only six or seven statutory instruments have ever been defeated, so regulations in themselves provide very little safeguard. This is our only opportunity to provide safeguards in the Bill. Essentially, the choice for us is to press on with amendments at Report or to come to some agreement with the Government about what is appropriate. That we need something in the Bill is not in doubt.

Health Service Medical Supplies (Costs) Bill

Lord Young of Norwood Green Excerpts

Committee: 1st sitting (Hansard): House of Lords
Monday 23rd January 2017 Grand Committee

[Baroness Walmsley (LD)]

My Lords, I support this amendment and compliment the noble Lord, Lord Warner, on his comprehensive introduction of it. I have no intention of repeating everything he said. However, I have a few points. I, of course, support the Government’s intention to try to make sure that the health service is not ripped off, but point out that a very large fine has just been imposed on Pfizer by the competition law regulations in relation to the case mentioned by the noble Lord, Lord Warner—so even without this Bill, that is working and we must bear that in mind.

What I am particularly concerned about is the potential effect on the life sciences sector, particularly—as the noble Lord, Lord Warner, said—in the light of Brexit. There are dangers to our markets and to our researchers. Our research is going elsewhere and researchers from other EU countries coming to us are all in danger because of the Prime Minister’s determination to take us out of the single market and the customs union, which I do not believe is what the public voted for.

The particular issue that concerns me is that although we were told in some of the meetings we had that there had been consultation and there will be more consultation before elements of the Bill are implemented, parts of the industry tell us that they are very concerned that they were not consulted. They do not feel that the level of consultation before the Bill is implemented is anything like good enough. We have to support our life sciences industry. We are very good at life sciences. It is one of the things that we can lead—and have led—the world on, but we must make sure that it is not in danger.

The other point is on access to treatments—not just drugs but other treatments. I am told by GPs that rationing is already in place, either by these referral management companies—private companies—that are being placed between the GP and his or her recommendation and the consultant, or by the consultants having pressure put on them to refuse consultation over certain patients referred to them by GPs. We already have rationing and we need to make quite sure that we are not affecting our pharmaceutical industry. We must ensure that our industries involved in research, medical implements, treatments, machines and devices and all those things that we are so good at inventing are not damaged by the Bill. It is really important that we have a statement of intent in the Bill. It will place on the Government the responsibility to make sure that they consider this terribly important sector. I have not had a chance to read the industrial strategy yet, but I would be surprised if the money follows the intent. I do not think that we will be able to look to that for any comfort, so we need this amendment.

[Lord Young of Norwood Green (Lab)]

My Lords, I hesitate before speaking about this amendment because I do not profess any particular knowledge of this area. I have not participated before on the Bill because I have been ensconced in dealing with the delights of HS2, but I have a couple of points to make. I am certainly sympathetic to the amendment, but something the noble Baroness, Lady Walmsley, said worried me. She said that even without the Bill, action is being taken. That does not mean that we do not need the Bill.

My first point is that it took quite a while for this to be exposed. It took the campaign from the Times to bring this to the forefront. Surely one of the questions we ought to be asking is why this was not exposed through the audit processes of the NHS in the first place. These were not small increases: they were staggering. One epilepsy drug that started off for a few pounds went up to something like £67. They were staggering increases—so that is one question for the Minister.

There are clearly differences of opinion about how effective the Bill is at getting the balance right, and that will be tricky. I can understand that listening to the arguments today. Nobody wants to stop the innovative, essential approach of successful British drug companies. That is on one side. But on the other, we have to ensure that the health service and the cost of drugs are protected.

A letter to the Times on Saturday caught my attention. It talked about the importance of clinical pharmacology and focused on the safe, effective and economic use of medicines. A recent report by PricewaterhouseCoopers stated:

“Each £1 spent to hire additional clinical pharmacologists has the potential to reduce NHS costs by almost £6”.


Apparently, there are only 72 clinical pharmacologist consultants working in the NHS. The British Pharmacological Society recommends that it needs a total of 150 by 2025. Without urgent action, therefore, the impact of waste is set to increase, and that surely ought to give us cause for alarm. Again, I am only giving notice to the Minister; he might not be able to give me all the answers to these questions.

Health and Social Care (Safety and Quality) Bill

Lord Young of Norwood Green Excerpts

Friday 6th February 2015 Lords Chamber

[Lord Young of Norwood Green (Lab)]

My Lords, I do not usually enter these debates because I do not necessarily feel that I have the knowledge to do so. I was impelled to do so—I must admit that it was a fairly late impulse—by the Bill’s title and then having a cursory glance at its substance. I was not expecting much humour in this debate but I am indebted to the noble Lord, Lord Willis, for the idea of chipping at birth. I have recently had that done to a cocker spaniel; I never thought of introducing it to my children when they arrived. It might not be a bad idea to keep track of them but I doubt that it will get through.

I wanted to speak in this debate because, apart from the matter of my own personal interaction with the NHS—I say to the noble Lord, Lord McColl, that I do not know whether they used indelible ink, but thank goodness they got the hip implant on the correct side, the left—whether or not the Bill goes through, there are still fundamental changes that all of us want to see take place in the health service, and which have been touched upon throughout the debate. To return to the noble Lord, Lord McColl, it strikes me as important to identify best practice, and I cannot help wondering why it takes so long for it to permeate. The noble Lord gave his example of how to ensure that accidents do not happen in the operating theatre. One that I have heard about recently is a tick-list system, rather like the one that they use when flying aircraft. It says that everyone in the operating theatre identifies who they are—I think that probably helps—and knows the nature of the operation, and so on; I shall not go through all of it.

Why is best practice not being extended at a more rapid rate throughout the health service? After all, we know where some of the best hospitals are; we can identify their performance. When I as a lay person enter hospital, perhaps because, as I have been recently, I am looking after an aged relative, I can see best practice. I can see when they are paying attention to whether their patient is eating his food or getting enough liquids. I can see whether they attempt to get a patient who has been immobile out of bed and exercised regularly, so that he or she does not leave hospital in a worse state than when they entered it. There is a danger of that, after all: they go into hospital still in control of their bodily functions but sometimes leave with a catheter and, if they are really unlucky, with double incontinence. It is so difficult to get this right.

I also have experience of some hospitals where one ward is operating to perfection but in another you wonder whether you are in the same hospital. Why does that come about? My view, and I think that my noble friend Lord Turnberg identified some of the issues, is that, apart from the intrinsic dedication of staff, which we hope we will experience, training and supervision are key. If the people in charge are just talking the talk and not walking the walk—if the ward sister or matron is not actively engaged in going around their ward, talking to patients and observing the culture—it will not happen.

Someone talked about changing culture. Anyone who has studied organisations knows that changing culture is the hardest thing to achieve, and in an institution as large as the NHS it is doubly so. I hope that the Minister will give us some assurance on the inculcation of best practice. The noble Lord, Lord Ribeiro, talked about wrong sites and wrong implants. The thing that I reflected on was not only the poor patients but the sheer cost to the NHS of such claims. We dealt with that recently in an Oral Question. I hope that the Minister will consider that.

I could not help but identify with my noble friend Lord Turnberg when he talked about the non-inclusion of children. I had not carefully looked at that measure before I realised that that was the case; I was thinking about NI numbers as an identifier when I suddenly thought, “Well, that won’t apply to children anyway, unless I’m mistaken”. I think that he is right about that criticism.

I do not feel qualified enough to say whether the overall impact of the Bill would be either negative or positive; I can see the positive points in it, but do not want to get caught up in the semantics of whether there was zero harm or reduction of harm because I do not feel qualified to be able to distinguish between them. We all share the same common objective that is in the Hippocratic oath: “Do no harm”. As a general dictum, if you like, I embrace the point made by the noble Lord, Lord Elton, about the perfect being the enemy of the good. As a trade union negotiator I have embraced more compromises, which sometimes I have described as “shoddy”, than have most of us—although most of us here have engaged in that. However, I never really regarded them as shoddy but as a natural part of any negotiation. Therefore I will leave it up to the experts to determine that.

I will say only one thing to the Minister: it is a worry that somehow, despite the excellent intentions of the Bill, we have not created enough time to ensure some amendment that might make it much more acceptable to the whole House.

Health: Influenza Vaccination

Lord Young of Norwood Green Excerpts

Tuesday 10th January 2012 Lords Chamber

Asked By

[Lord Young of Norwood Green]

To ask Her Majesty’s Government what steps they are taking to ensure the take-up of influenza vaccination among those who work in the health and care services.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, this winter NHS employers ran a staff communications campaign to increase awareness and uptake of the flu vaccine in front-line healthcare workers. The department wrote to NHS trusts, medical royal colleges, professional bodies and the social care sector for their support in increasing uptake in this group. Good progress has been made. Uptake in healthcare workers to the end of November was 40 per cent, more than double what it was by this point last year.

[Lord Young of Norwood Green]

My Lords, I thank the Minister for his statement and welcome the improvement, but does he agree that there is still a significant way to go? Indeed, Professor Openshaw, the director of the Centre for Respiratory Infection at Imperial College London, said that in his view healthcare staff should be vaccinated and wear a badge saying, “I’ve been vaccinated. Ask me why”. I am not suggesting a compulsory approach, but more front-line education of staff would be a step forward, as would making vaccination available to health and care workers at their place of work. I would welcome the Minister’s comments on those points.

[Earl Howe]

I agree that there is some way to go. It is encouraging that we have made significant progress this year. Of course, the season is not yet at an end, and we hope that more healthcare workers will still be vaccinated. Uptake rates in healthcare workers have historically been low, as the noble Lord will be aware. A number of reasons have been suggested for that, but there is no doubt about the importance of this issue. Part of the reason is the need to ensure that healthcare workers do not transmit flu to those they are looking after. Also, it is in the interest of employers to ensure that absenteeism for sickness reasons is kept to a minimum.

Nursing

Lord Young of Norwood Green Excerpts

Thursday 1st December 2011 Lords Chamber

[Lord Young of Norwood Green]

My Lords, I, too, thank the noble Baroness, Lady Emerton, for initiating this debate and congratulate her on a superb contribution. I enjoyed the history of nursing but must admit that I felt that one name was absent—especially as we are talking about front-line nurses—and that was Mary Seacole, who brought a different approach, though a very interesting one, about the same time as Florence Nightingale. I see that I have not transgressed because the noble Baroness is nodding. I am relieved that I have got my history right.

I enter this debate as a lay person, but I cannot help thinking that if Benjamin Franklin were alive today and living in the UK, he might be saying that there are three things that are certain: death, taxes and—whoever we are, at some point in our life—being impacted on by the National Health Service. Of course, the unfortunate fact is that as we gradually mature—I do not say get older; in the House of Lords we mature—we experience that impact. Last year I spent a week in an NHS hospital having a large lump of titanium inserted in to my hip. It was largely a very good experience. It was fascinating being in the ward, looking at the atmosphere there and the nature of the people who treated me. As has been said, some were absolutely superb: they had empathy, compassion and all the things that you want. Others, I could not help feeling, needed to be taken to one side and told, “Look, part of working on a ward is to show care, empathy and compassion. If you’re not doing that—it doesn’t matter who you are, whether you are a doctor, nurse or care assistant—you are actually undermining the quality of care for people who are really at your mercy as patients”.

When it is good, it is really good. I noticed this during that week. There were some ward sisters who came on and would do anything; never mind “too posh to work”, they would do any job whatever. They were a brilliant example of leadership at its very best. There were others with whom I felt that it was not quite right. The worst example that I saw was when the elderly woman with suspected pneumonia in the bed next to me was getting in to that panicked breathing mode. In a plaintive voice, she said, “Help, nurse. Help”, and a young nurse who was sitting at a computer turned round and said, “Someone will be along in a minute”. I had difficulty in restraining myself at that point and fortunately someone did come along, but why did that nurse not get off her backside and do what she should have done, which was to respond to the woman while holding her hand? It is a matter of changing the culture—something that has already been referred to. I hesitate to bring up the worst examples but, if we do not have an honest and frank debate, we will not really address the issue.

However, as I said, I have seen some wonderful examples. My wife is currently being treated for a serious kidney condition and the renal ward at Hammersmith Hospital is absolutely brilliant. I reckon that the senior ward sister there—Sister Nicola—would be able to solve most of the problems in the National Health Service if only we could clone her. She is marvellous and empathetic, and the ward runs like clockwork, and so there are some absolutely brilliant examples.

My noble friend Lady Warwick rightly condemned the generalisation that takes place in the media by implying that, if you have a degree as a nurse, somehow you cannot undertake basic nursing tasks. I, too, reject that—it is clearly wrong. However, we have to make sure that the training for people who study for a nursing degree is right. As I understand it, they should spend 50 per cent of their time on the wards. I should be grateful if the noble Earl, Lord Howe, could confirm whether that is the case when he responds. Ward experience under the watchful eye of trained sisters is vital.

My noble friend Lord Hunt, who seems to have captured the ground in progressive approaches to the development of nursing, gave us some very useful pointers. Why do nurses not have something equivalent to the doctors’ Hippocratic oath? My noble friend was absolutely right to talk about a code of values. That ought to be taken on board and be a part of the national scheme. Knowing who is in charge and has authority is important. Going back to one of the best examples that I had experienced, when I asked Sister Nicola what her qualifications were and whether she had been in the nursing profession for a long time, I discovered that she actually had only a diploma. I am not arguing against degrees but, with my passion and enthusiasm for apprenticeships, I argue that there should be a vocational route into nursing. Interestingly, when I asked the consultant for her views on this, she said, “It’s funny you should say that. We have a healthcare assistant who is a mother. She has returned to work recently and wants to go into nursing”. There ought to be that vocational route for healthcare assistants. I am reminded of the old sandwich courses that you did if you wanted to get a degree in engineering. Again, when the noble Earl replies, I should be grateful if he could take up that point.

The noble Baroness, Lady Browning, said that there are a number of practical things that can be done—my noble friend Lord Hunt told us about some of them—and that we do not need another five years of research to encounter what we know to be proven good practice. I hope that the noble Earl, Lord Howe, will be able to assure us that spreading best practice will be one of the Secretary of State’s key roles. It is not just about money; there is a real debate about staffing, although I do not want to go into that. Obviously if people feel under real pressure, that is going to create problems. I do not particularly want to explore that side of the issue but spreading best practice, as a key part of developing the health service, seems to be fundamental. Surely it would be a cost-effective, value-added method of improving the health service.

I have one or two points to make in conclusion. The noble Baroness, Lady Browning, touched many buttons when she talked about the confusion over uniforms. I absolutely echo that. You think, “That one’s in blue, that one’s got blue with spots on and that one’s in pale blue”. Sometimes it is also really difficult to distinguish healthcare assistants.

There is a question over whether healthcare assistants should be regulated. I tend to feel that, because they have become so important to hospitals and community care, the one thing that we should insist on is a requirement for basic training. That should not be an option. Perhaps a code of values, which my noble friend Lord Hunt suggested in relation to nurses, should also be adopted for care assistants.

A number of contributors said that it was important to make sure that those in charge of wards have authority. I have recently been in hospitals where the wards have been spotlessly clean. That is one part of the problem in wards but it is not the only one—noble Lords have also referred to the feeding of patients and so on.

I am conscious of the time but I should like to make a final point. I think that it was on the “Today” programme on Radio 4 this morning that I heard a former nurse speaking about whistleblowing. I do not like that phrase either, because it should not have to happen. The right management environment should encourage people, as part of working in a team, to explore the strengths and weaknesses of their work on a ward. They should be able to say, “How can we work together? If there are problems, I should be able to feel that I can go to my immediate manager and have a frank discussion”. It is important to ensure that the right processes are in place to enable nurses to feel confident enough to do that.

In conclusion, I feel privileged to have had the opportunity to take part in this debate and I look forward to hearing the noble Earl’s response.

--- Later in debate ---

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, on occasions like this, I reflect on how lucky we are in this House to have the noble Baroness, Lady Emerton, in our midst. She has allowed us to appreciate once again why she is such an unquestioned authority on this crucial subject of nursing care. I, for one, am very grateful to her.

The wording of her Motion is of course carefully chosen. Front-line nursing—in acute settings, in the community, in schools and in people’s homes—is a part of all our lives and has always been an essential element of patient care in the National Health Service. Patients are clear about what good nursing care should look like. They want to be confident that their nurses are knowledgeable, safe and competent. They expect their nurses to be caring and compassionate. They want to be treated with respect by nurses who genuinely care for them and about them.

We in Government are also clear about what we expect from a front-line nursing workforce. I cannot better the description offered by the noble Baroness, Lady Warwick. We expect high-quality, safe and knowledgeable care for all; we expect dignity and compassion for all; and we expect nurses to make the most of each and every interaction they have with patients to improve their health and well-being, and their experiences of care.

What makes a good nurse? The first requirement is a point raised by my noble friend Lord Bridgeman. We should attract people into the profession who not only have academic ability, but also have the right values, attitudes and behaviours. Education commissioners expect universities to demonstrate that their recruitment processes embrace this approach. Employers will also look for this as part of their selection and recruitment processes when they are helping to interview potential students and are appointing registered nurses. Getting this right at the start will help to reduce attrition and maximise the resources that we put into nurses.

The second requirement, as our debates on the Health and Social Care Bill have amply demonstrated, is that we educate and train our nurses well. The Nursing and Midwifery Council undertook a comprehensive review of pre-registration education and published new standards for pre-registration education in 2010, following extensive and wide public consultation. Importantly, fundamental care is specifically reflected in these new standards. I would say to my noble friend Lord Bridgeman that student nurses spend as much time gaining practical, hands-on experience with patients as they spend in the classroom. In fact, I believe that that ratio has not changed over the past 30 years. I completely agree with the excellent points made by the noble Baroness, Lady Warwick, about degree-level nursing. The first of the new educational programmes began only this year and it will be about three years before the first students emerge from these new programmes. The NMC will evaluate these changes and I look forward to seeing this work.

The next requirement is to enable nurses to nurse. That means doing what the noble Baroness, Lady Masham, talked about so compellingly: finding ways to make sure that we keep senior, experienced nurses beside patients delivering hands-on care and not filling in endless piles of paperwork, which are sometimes of marginal usefulness. That is why we are committed to reducing bureaucracy and empowering our nurses as clinical leaders. The NHS institute’s productive series is helping nurses to reduce unnecessary and wasteful practice at the point of care, which is freeing up nursing time to be spent on essential tasks, such as providing assistance with mealtimes and carrying out interventions to prevent pressure ulcers and falls. Any good nurse will tell you that spending more time with the patient facilitates a better and more timely patient assessment, thus enabling the nurse to spot signs of deterioration or to pick up on small but significant things that a patient often will not think to mention. That is why my officials are working with the NHS institute to explore ways in which areas that are not yet embracing the productive series can be identified and supported with implementation, thus allowing the spread of best practice, about which the noble Lord, Lord Young of Norwood Green, spoke.

A phrase that I have learned recently is “essential rounding”, a system that sees nurses doing planned rounds every one to two hours to check on patients and to deal with any concerns. We are pleased to see nurses embracing that concept. Feedback about it from patients and nurses is very positive, with some studies seeing a reduction in falls and improvement in patient experience since implementation. In fact, a plethora of best-practice guidance is available. But central initiatives can take us only so far, which is why effective nursing leadership at the front line is so important. Matrons and senior nurses are role models and they are pivotal in developing the culture of care in their clinical areas. Through the standards they set for others to follow, to monitoring the performance of individual nurses, they ultimately make the difference between good and bad care.

I welcome the work of the NHS institute in developing a clinical leadership competency framework which will help develop patient-centred nursing leadership. The noble Lord, Lord MacKenzie, whom I welcome to the Front Bench, was right that the vast majority of nurses are extremely professional, care deeply about their patients and do a tremendous job, often under very difficult circumstances. But, at the same time, the noble Lords, Lord Young and Lord Hunt, were right to be honest that this is not always the case. The CQC’s report on its 100 unannounced nurse-led inspections showed how the quality of care—in this case, for older people—can fall far short of what we would want. That problem is far more widespread than we would expect. About half of hospitals visited gave cause for concern. Twenty hospitals were not delivering care that met the essential standards that the law says people should expect. I was alarmed to see that in 14 hospital trusts fewer than half the staff said that they would be happy to see a friend or relative treated in their own hospital.

However, I would say to the noble Lord, Lord MacKenzie, that I do not think that it is right simply to say that this is because of poor staffing. The CQC dignity and nutrition inspections found many examples of excellent practice where staffing was not ideal and cases of poor nursing care where there was a full staffing complement. We are hearing more and more concern from patients and nurses themselves about inadequate staffing levels and inappropriate use of support workers. As I said in our debate yesterday, setting safe staffing levels is not an exact science. These decisions are complex and they are best made by local clinicians and managers on the ground, who understand the needs of their patients. As noble Lords are aware, there is guidance available from the RCN and others to assist clinicians and managers in setting safe staffing establishments.

This same guidance is used by the CQC when determining whether providers have enough suitably qualified, skilled and experienced staff. The CQC can take tough and independent action when an organisation is not taking appropriate steps to ensure that there are sufficient numbers of suitable staff at all times. The noble Baroness, Lady Emerton, mentioned Anne Marie Rafferty’s research. I would be pleased to look at that research in detail and I will ask the Nursing and Midwifery Professional Advisory Board to consider it and report back to me early in the new year.

Much of the concern around nursing in acute settings has been related to inappropriate delegation by nurses to healthcare support workers. Wherever there is a multidisciplinary team of regulated professionals and unregulated healthcare workers, appropriate delegation and supervision is vitally important. This is an area ripe for formal review. We very much welcome the NMC’s plans to update its guidance on delegation so that nursing staff know how to do this safely and are clear that they retain responsibility for their actions. We have also asked Skills for Health and Skills for Care to accelerate production of a code of conduct and recommended core training for healthcare support workers and adult social care workers in England. We expect work to begin by April 2012, with the aim of delivering outputs ahead of the establishment of an assured voluntary register, which could be operational from 2013 onwards.

Nurse leaders, managers and trust boards must take staffing concerns seriously and, where staffing is found to be an issue, they must take immediate action. In the new world of the NHS, there will be two watch words for commissioners: outcomes and quality. This carries the basic point that clinical commissioning groups will want to satisfy themselves that the services they commission have safe and effective staffing profiles. Nurses will have an increasing role in commissioning and in developing the shape of local services—that is exciting.

Safe and effective care has several strands to it, all in the direct gift of nurses. Noble Lords may be aware of the QIPP safe care work stream quality improvement programme—the safety thermometer—which aims to focus nursing attention on four areas of harm: falls, blood clots, pressure ulcers and catheter-related urinary tract infections. We have published the 2012-13 operating framework with strong messages about reducing harm in these areas, making sure that these are firmly on trusts and commissioners’ agendas.

My noble friend Lady Browning spoke of the need for government leadership and she is right. We are making sure that the nursing contribution to quality is being championed at the very centre of government. The SHA chief nurses are leading the nursing contribution to quality improvement at the front line through the energising for excellence quality framework. Much of the success of the quality framework will depend on transparency and, as part of our transparency agenda, NHS North is working towards local publication of nurse-sensitive metrics in areas such as falls and pressure ulcers and is also exploring how best to include patient and staff experience data. The patient experience is absolutely centre stage as we set about measuring the quality of nursing care. Ensuring that patients have a positive experience of care is reflected in the NHS outcomes framework that the new NHS Commissioning Board will use to hold the NHS to account for what it delivers. Everyone who works in the NHS has a role to play in ensuring that patients have a good experience. It is not optional, and it is not “someone else’s job”. The task is to make listening, understanding and responding to patients’ views as commonplace as acting upon clinical audit data, patient safety data or financial data.

Nurse training has, unsurprisingly, featured prominently in this debate. The noble Baroness, Lady Warwick, raised the issue of continuous professional development. Later this month, the Government are publishing our detailed proposals on education and training that will describe the arrangements for continuing professional development, which we recognise is of great importance. My noble friend Lady Jolly spoke about the role of specialist nurses and her concern about downgrading roles without due regard to patients’ needs. I agree that service planning has to put patients firmly at the centre. The Government acknowledges the important role of specialist nurses in improving health outcomes and patient experience. In the end, local organisations must have the freedom to determine the skill mix of their clinical teams. Commissioners, clinicians and trust boards have to work together to ensure that the workforce is capable of meeting the needs of patients and that they have access to continuing professional development.

My noble friend also spoke about the introduction of end-of-life care standards, and I am happy to assure her that we will continue to work towards implementing the end-of-life care strategy.

The noble Baroness, Lady Masham, spoke with her customary force about bringing back old-style matron. That resonated throughout your Lordships’ Chamber, and there is no doubt that strong nursing leadership is essential at all levels for high-quality care. The noble Lord, Lord Hunt, was quite right about that. Directors of nursing and trust boards must set the culture for a hospital, and that includes a leadership style that challenges poor standards and creates an environment for high standards.

My noble friend Lady Browning raised the subject of whistle-blowing. It is very important that the culture of a hospital is right to enable whistle-blowing to happen. Leadership from boards has to set the tone for that. To whistle-blow does require great confidence and support. I believe that more of this will come because of the increase in graduate nurses.

All this has a direct bearing on the point made by my noble friends Lord Bridgeman, Lady Browning and Lord Ribeiro about cleaning. Nurses have a key role to play in ensuring that hospitals are kept clean. The infection control nurse, the ward sister and matron who set and enforce local standards are particularly important. The code of practice for the prevention and control of infections ensures that nurses are involved in all aspects of cleaning standards. The code provides that directors of nursing are involved in all cleaning contract negotiations, which is very important. Matrons have personal responsibility and accountability for delivering a clean safe environment for care.

The noble Lord, Lord Hunt, mentioned supernumerary sisters. The RCN has just published guidance on developing business cases to fund the supervisory status of the sister so she can exercise her leadership role effectively. The guidance is helpful, timely and above all very practical.

The noble Baroness, Lady Masham, spoke of the importance of district nurses—again, absolutely to the point. We acknowledge the enormous contribution of district nurses in helping people manage long-term conditions, keeping people out of hospital and ensuring people are able to access the resources they need, when they need them. We want to make sure that people go to hospital only when they need what a hospital can do. We see a much greater role for district nurses in the future, not a diminishing one.

The noble Baroness, Lady Warwick, and others mentioned the RCN Frontline First report. I do not want to dwell too long on this, but I have to voice some serious criticism about that report. The RCN’s numbers are mainly based on an analysis of just 41 trusts. The trusts identified in the report have disputed the RCN’s figures. The RCN has not offered commentary on the fact that some of these plans are about moving services out into the community to provide better care for people when and where they need it. We are not disputing that some trusts have reduced the number of staff—some have—although many of these are support staff and often it is being done through natural turnover. We do emphatically reject the conflated numbers that the RCN is claiming. I have got some chapter and verse in my brief, but all I would say is that it is up to local trusts to determine their workforce needs. We have made it clear that any reduction in clinical posts must not have an adverse impact on the quality and safety of patient care. We have introduced a quality assurance process for SHAs to complete with trusts.

The noble Lord, Lord Patel, spoke about midwifery. The Government are not reducing the number of midwifery trainees. In 2010-11, 2,488 midwives training places were planned. A further 2,507 training places are available this year—that is a record high. The Government are committed to ensuring that we have the right number of trained midwives, especially given the increased number and complexity of births in recent years. This includes ways of supporting midwifery recruitment and retention to help local organisations which are able to commission the number of training places that they need. We have asked the Centre for Workforce Intelligence to undertake an in-depth study of the maternity workforce starting this year. This will inform the future commissioning of training places, including for midwives.

On specialist neonatal nurses, I took the points that the noble Lord made. The National Institute for Health and Clinical Excellence quality standard and the toolkit for high-quality neonatal services are valuable tools to assist NHS commissioners and providers in the provision of high-quality care for babies and their families. However, I shall take away the points that the noble Lord raised.

We have heard today from my noble friend Lady Jolly, among many others, about the opportunities for front-line nursing. Technology moves on, medical knowledge is constantly advancing and the members of our nursing workforce will need to keep abreast of these changes. But one thing that we know will not change is the importance of the care that nurses deliver; and the key role that nurses can and do play in improving quality of care, patient outcomes and their experiences of care.

[Lord Young of Norwood Green]

Will the noble Earl comment on my point about a vocational route into nursing?

[Earl Howe]

In the time available, I shall do so very briefly. Access to nursing is, as the noble Lord will know, already through quite a wide entry gate—through progression from apprenticeships, NVQs and access courses. Universities set the entry standards and do not always rely on A-level qualifications. However, it is important that students must be able to cope with degree-level study—it would be wrong to set them up to fail. However, we are aware that the entry gate about which the noble Lord, Lord MacKenzie, spoke needs to be as wide as reasonably possible.

It is patients who matter most. As a Government, we are committed to bringing about the improvements in front-line nursing care that patients want.