Health and Social Care Bill

Lord Patel Excerpts

Monday 19th December 2011 Lords Chamber

Debate on Amendment 338 resumed.

[Lord Patel]

My Lords, I shall speak to Amendments 338 and 340, to which I have added my name in support of the noble Baroness, Lady Emerton. For those of your Lordships not familiar with the amendments, they are to do with the regulation of healthcare support workers. As many noble Lords will know, these workers were introduced into the health service just over a decade ago, and they are untrained, unqualified and unregulated. There are 300,000-plus of them in the health service, with many more working in nursing homes.

Any debate about the regulation of healthcare support workers will need to take account of current workforce trends. In April 2011, the Royal College of Nursing reported that NHS trusts were increasingly looking to reassess nursing roles in order to deliver short-term reductions in the wage bill without a full clinical assessment of the impact of this action on patients’ safety and the quality of patient care. The RCN reported a notable change in the skill mix of teams, with an increased reliance on unregulated healthcare support workers.

The other workforce in nursing is trained and regulated. It is made up of registered general nurses and registered midwives, and we also used to have state-enrolled nurses. The view could be taken that it is the responsibility of employers to make sure that their workforce is adequately trained and has the skills to deliver the care, but many recent reports with which noble Lords are familiar highlight poor-quality nursing care. Some of them have appeared in the press and include the failings at Stafford Hospital, where hundreds died unnecessarily, and at Winterbourne View care home, where staff were filmed abusing vulnerable patients, as well as a series of critical reports, most recently from the Care Quality Commission, which has condemned NHS care for the elderly. Some, including regulatory authorities and particularly the Council for Healthcare Regulatory Excellence, favour the employer-led model of training of healthcare support workers or of those who are not trained yet provide nursing care. This model was introduced in Scotland. The important thing is that it has never been evaluated. That needs to be done first. Secondly, and more importantly, the ratio of trained nurses to untrained support workers is quite different in Scotland. Anyone who promotes this model needs to look at that first.

I return to some of the issues. The noble Baroness, Lady Emerton, made all the points in an excellent introductory speech. It is a pity that we did not have a continuation of the debate so that we could have heard her comments and responded to them. However, the Bill proposes that the regulators of healthcare professionals should have the ability to establish voluntary registers for currently unregulated workers and professionals who are, or have been, engaged in work that supports or otherwise relates to work engaged in by members of the profession that the body regulates.

In proposing voluntary registration, the Government have accepted that unregulated workers supporting healthcare professionals represent a risk to public protection that needs to be addressed. If they did not, why would they even consider voluntary registration? It must be because they think it is a risk. Voluntary registration for healthcare support workers carrying out tasks delegated by nurses or midwives is not sufficient to protect the public.

The other argument used is that it is the trained nurses—the registered nurses—who supervise these support workers who are not trained or regulated. How can a nurse, or two nurses, in a ward of 15 or 16 intensive care patients, supervise three or four unregulated, untrained workers, who then carry out nursing tasks? The noble Baroness, Lady Emerton, cited a real case of such a worker measuring blood pressure who did not understand why she was doing it. If one is going to have people who look after ill, frail people, one needs to make sure that they are trained properly, that their training is assessed, and that they are regulated. I understand that this cannot be done overnight, particularly as we now have nearly 400,000 such people working in the health service, but there ought to be some mission to do this in a relatively short time, maybe even in two or three years. To go after voluntary registration is not the answer.

There is currently no consistent UK-wide training standard for healthcare support workers. Courses can range from an hour-long induction up to NVQ level 3. Assistant practitioners are experienced health support workers. They are different, and they may receive training up to NHS-level band 4, which is equivalent to the level of the previous state-enrolled nurses, but, again, there is no consistency across the UK. Clause 231 gives no indication that a voluntary system will be underpinned by consistent UK-wide standards of training that will assure the public that employers who employ health support workers have the knowledge and skills that they need to practise safely. I strongly support this amendment. Whenever the noble Baroness wishes to call a vote, I will join her.

[Lord MacKenzie of Culkein]

My Lords, I have long been an advocate in the cause of statutory regulation and registration of healthcare support workers. When one has been around the health service for a long time, it is not unusual to see the wheels turn full circle. We went from support staff to auxiliary nurses, to nursing assistants, to state-enrolled assistant nurses. Then the word “assistant” was dropped and we had state-enrolled nurses. Then, as the noble Baroness, Lady Emerton, said earlier, the roles of the state-enrolled nurse and the registered nurse became very confused and the titles became interchangeable, which should never have happened. Then we moved to Project 2000 and the move from hospital-based training to higher education, and we are now moving from diploma to an all-degree profession, which is right and proper.

In 1999, my union, the Confederation of Health Service Employees, supported Project 2000, but we foresaw a gap that would be left by the ending of enrolled nurse training, which would lead to there being many more auxiliaries or healthcare assistants, as they became. We called for support workers to have about a year’s training to an agreed national standard and statutory regulation by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, as the regulatory body was called. We did not get that. The idea was opposed because it was argued that it would replicate the then existing confusion between enrolled nurses and registered nurses.

Where are we now? We have an explosion in the number of support staff who have taken the place of enrolled nurses; there are far more than any of us ever envisaged at the time. As the noble Lord, Lord Patel, said, more than 300,000 support workers are now employed in various roles with a number of job titles. One figure that I saw in research produced by UNISON said that there were more than 120 different job titles for healthcare support workers, which is astonishing.

We have a situation in which the patients do not know who is caring for them. It is not just a question of uniform, although that is important. Support staff carry out many duties that were previously the role of regulated nurses. Many of those roles, such as nasal gastric tubes, cannulation, catheterisation and blood pressure, are intimate and invasive, as we have heard. Almost uncannily, in view of what the noble Baroness, Lady Emerton, spoke about, I spent some time in hospital a couple of years ago when I had my blood pressure taken sitting in a chair beside the bed and my diastolic pressure was down to 40. I said to the healthcare assistant who took that blood pressure, “I had better get back to bed and I think you’d better call a senior nurse and doctor”. She said, “No, you are going down for an MRCP scan; just sit where you are”. Fortunately, being a nurse, I knew what I was talking about and I was able to get a doctor and a nurse, and before very long I had massive amounts of fluid pumped into my veins to restore my blood pressure. Had I not understood the situation, that could have resulted in a serious condition. It is quite frightening. You can be trained to take blood pressure, but not trained in the skills of observation and in understanding the readings that are being taken.

With the drive to reduce costs, there is, and will be, more substitution of registered nurses by healthcare workers. In effect we have a new second level, but that new second level is not regulated and not registered and the staff are not professionally accountable for their practice. That is not good enough. That is not in the interests of patients’ safety or protection. Nor will assured voluntary registration deal with the matter. Voluntary registers already exist for other professions and there are very real concerns about their inadequacies. They have no teeth, and staff can leave a voluntary register, particularly if there is any investigation for possible discipline.

The registration and regulation of healthcare support workers is supported by the Nursing and Midwifery Council, by the Royal College of Nursing, and by UNISON, although in fairness I should say that UNISON would prefer registration by the Health Professions Council. Registration is supported by the Queen’s Nursing Institute, by the health committee in another place and, most importantly, by healthcare assistants themselves.

In the Nursing Times of 6 December, I was interested to see in a small article about the Mid Staffordshire NHS Foundation Trust public inquiry that Robert Francis QC spoke of 20 issues that he would consider when drawing up his recommendations, which are due to be published next year, and the regulation and training of healthcare assistants was to be first on the list. I hope that that does not mean that they will carry the can for all the problems in Mid Staffordshire because that is certainly not the case; they go to a much higher level than that. Counsel to the inquiry, Tom Kark QC, said that the lack of regulation of healthcare assistants appeared to be surprising and dangerous.

There is inexorable pressure for this matter to be dealt with—and dealt with soon. It is not something that can be put on the long finger. If there is a strong recommendation from the Mid Staffordshire inquiry, we cannot leave it to be dealt with in a future Bill because we will not be getting another health service Bill for some time. This Bill gives us the opportunity to do this and to get it right. I strongly support the amendment by the noble Baroness, Lady Emerton. Healthcare assistants who have work delegated to them by nurses should be properly regulated and registered.

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[Lord Patel]

I wish to pick up on one point. Can the noble Baroness reassure us on what it is she will keep under constant review? I understood her to say that the Government will rely on employers to ensure that these support workers have some kind of training. There will be no national training standards and, once the employers are satisfied that these people have some kind of training, they will be entitled to go on a voluntary register. As I understand it, the logical thing here is first to establish a national standard of training; then to ensure that those national standards are implemented; and then to allow people to register. If they register, the next step would be regulation. The first step is not immediate regulation but national standards of training and assessment that those standards are being met, before people can go through any kind of registration. What is the noble Baroness agreeing to keep under review?

[Baroness Northover]

I should perhaps explain that more precisely. This issue will be constantly under review so that if there are concerns in this area they will be flagged up. The Government will of course continually consider how best to respond and make sure that standards are of the quality that we need. The noble Lord is right: national standards of training are indeed the start. Then people are admitted to a register and so on. A voluntary-assured register would demand that kind of national level of standards in training. I hope that in that regard I can at least reassure the noble Lord.