(12 years, 11 months ago)
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Baroness Emerton
My Lords, I welcome the opportunity to introduce this debate to take note of first-line nursing care. The timing of this debate is opportune for several reasons, not least that the Health and Social Care Bill is currently in Committee, giving an opportunity for amendments to the Bill that are considered helpful to the implementation of the proposed Health and Social Care Act.
The professions of nursing, midwifery and health visiting—the largest single workforce in the NHS—plays an important part in delivering high-quality care to patients. The NHS is currently facing the Nicholson challenge of saving £20 billion within the next three years, not avoiding cuts in service provision. The scene is therefore one of challenge: meeting the forthcoming organisational changes while maintaining and developing new approaches to the delivery of high-quality care. That inevitably causes a mixture of anxiety and excitement: anxiety for job prospects, but excitement at the opportunities opening to the profession by moving to an all-graduate profession and by meeting the patient’s needs holistically, with integrated patient pathways through primary, secondary and tertiary care, then back to primary care and care in the community, where the patient can be cared for in their home and supported by the NHS and social care with as much independence as possible for the individual and closeness to their family.
Where do the professions of nursing, midwifery and health visiting want to see themselves in the newly reorganised health and social care services so that they can deliver the high-quality care required and innovate in developing the new procedures that will result from research evidence, which will in turn result in best practice and be cost-effective? I declare my background in nursing. I am retired and not on the effective register of the NMC. I am a fellow of the Royal College of Nursing and president of the Florence Nightingale Foundation.
I should like to address concerns that have been raised in recent months about the move to degree-level registration for nurses. As my fellow commissioners set out in the report Front Line Care, degree programmes equip nurses and midwives to work in many settings and roles and draw on a wider repertoire of knowledge and skills, including the capacity to make complex assessments and clinical decisions and deliver therapeutic interventions in situations that are often unpredictable and emotionally charged. I would emphasise that these skills include effective communication skills and, in particular, how to provide care in a compassionate way. Any nurse practising in the 21st century care setting must have all these skills. We must also remember that 50 percent of university-based education programmes, at both degree and sub-degree level, continue to be delivered in practice. In moving to a degree-level profession we are following what is already in position in Wales, Scotland, several countries in Europe and elsewhere, as well as in professions such as midwifery and physiotherapy. Recent changes to pre-registration nurse education, as set out in the Nursing and Midwifery Council standards, will equip nurses to lead and deliver care and will ensure that nurses of the future are equipped to work within a modern healthcare system, while ensuring that care continues to be delivered with compassion.
It is vital that the focus is not just on what education and training nurses and midwives should receive in their pre-registration courses. Equally important are the development of post-qualification training pathways for nursing, which are sadly not funded in the same way as our medical counterparts. The funding exists in the current education and training budget to fund junior doctors’ salaries and postgraduate placements to training. We wish to see this extended to nurses and midwives so that they can continue to improve and develop throughout their careers and in particular, in the early years after registration. I would be very grateful if the Minister could confirm if the forthcoming publication of education and training will address the lack of central funding for post-qualification pathways for nursing, midwifery and health visiting.
The Royal College of Nursing, the Royal College of Midwives and the Queen’s Nursing Institute have all recently published reports reflecting the staffing levels currently being experienced and the urgent need to address the whole issue of workforce planning, taking into account the recommendations in the current Bill. The increase in community care is going to require an increase in community nurses—that is, district nurses—to meet the nursing care needs of those transferred from secondary care following admission to hospital, those suffering from long-term conditions, the treatment of the elderly, frail and vulnerable who require care and support to live independently, and not forgetting those who choose, in increasing numbers, to have end-of-life care at home.
These demands from the community will require highly qualified nurses facing a very different setting, with support and mentoring to adjust if moving from secondary care into the community setting. This means that the workforce planning for the forthcoming changes in the community will need to include the training requirements, not only the professional qualifications, for an induction into health and social care spanning NHS and local government management systems, and third sector involvement in health and social care. The specialist nurses for long-term care, for example Parkinson’s, multiple sclerosis and cancer care, play an important part in maintaining the patient to stay in the community and will form part of the community team that supports these patients. The increase in demand on the mental health service will need community psychiatric nurses, not forgetting those with learning difficulties.
Working in the community places different demands on the community nurses than those working in secondary care and there is much to be learnt in regard to working with social services and voluntary organisations, and not least the families, carers and neighbours of those for whom they care.
Research evidence from the United States, Canada, Australia and here in the UK clearly demonstrates that a higher ratio of registered nurses to support workers results in lower mortality and morbidity. It shows that 26 per cent of patients are more likely to die where nurses have the heaviest work load and 29 per cent are more likely to die after a complicated hospital stay. Seventy-two per cent of nurses with the heaviest workload showed negative job outcomes, burnout and job dissatisfaction and saw their hospitals’ care standards deteriorating.
Aiken’s study in the US demonstrated that every one patient added to the average, hospital-wide nurse workload increased the risk of death following common surgical procedures by 7 per cent. The UK evidence was recorded in 2007 by Anne Marie Rafferty. I ask that this research evidence be studied by the Government and that a cost-benefit analysis be worked on to see whether workforce numbers could be refined to take account of these findings in order not only to reduce morbidity and mortality but also to shorten length of stays, improve clinical outcomes and reduce infection, readmission rates and possibly the number of hospital beds. It should be recognised that community staff should be trained and in post in order to receive the increased workload.
Any reorganisation of services requires an in-depth analysis of the effects that the changes are going to cause and the means of solving the identified issues. As the nursing and midwifery professions and health visitors form the largest single part of the NHS workforce and play a vital part in delivering high-quality, safe care with compassion, respect and dignity, the implementation programme requires leadership from the profession nationally and at CCG level, as well as at the point of delivery of care, from ward sisters in secondary care and from nurse and midwife leaders in the community.
Nursing could best be described as the art and science of delivering high-quality, evidence-based care. The history of nursing demonstrates that nurse leaders effected changes in the development of the profession by exercising their powers of leadership through influence and persuasion, a leadership exemplar being Florence Nightingale, who influenced practice, education, research and public health and through evidence presented to politicians. Mrs Bedford Fenwick introduced the nursing register and regulation in 1919 after attempting to have six Private Member’s Bills passed in Parliament and 30 years’ struggle. Other examples are the Salmon report, which many nurse leaders influenced, as they did with Halsbury, Platt, Briggs and the royal commission that led to the nurses and midwives Act 1979, the establishment of the UKCC and national boards and education moving into universities. Again, a time span of nearly 25 years was involved.
The involvement of politicians has been central to the implementation of these changes. One could describe politics as the science of government. Nurses, midwives and health visitors need to exercise their leadership skills by influencing and persuading government with evidence that will lead to changes in the profession, leading to higher-quality, evidence-based, safe and cost-effective care to the satisfaction of patients, relatives and the public. However, while it is recognised that implementation of research-based change takes time, can we wait 30 years to see a reduction in morbidity and mortality rates among patients?
Given the current economic situation and the recent negative reports on care delivery, there is a very important task to be achieved in regaining the public’s and patients’ confidence in the profession. There is no doubt that we have excellent nurses and midwives throughout the country, but sometimes there are failures, usually due to a systems failure in the organisation. It is therefore important that the status of the professions is raised in the eyes of the public and patients. This can be done only by addressing the professional issues as well as the organisational team, starting with the board, providing them with clear sets of values and objectives to which the whole organisation is committed, with clear lines of accountability and authority.
My passion is to see nursing care of world-class standard, but as well as attacking the issues within the profession there is the overriding need to address the culture within the NHS so that all professions and support staff are committed to ensuring that the part they play contributes to the change in culture—that is, compassionate care with dignity and respect throughout the workforce; and staff valued, which in turn is projected to all patients, relatives and the public, restoring the view that the NHS provides excellent compassionate care with dignity and respect to all. This would override the rather negative and critical view that pervades at the present time in some places. I beg to move.
Viscount Bridgeman
My Lords, I thank the noble Baroness, Lady Emerton, for her expert and sensitive treatment of this subject. I am afraid what follows now will be a slightly inadequate summary of what she began by saying and reverted to later in her speech—that is, the fundamental challenge to the training of nurses in the United Kingdom. As she reminded us, the trend over the past 10 years towards the requirement that nurses should be educated to degree standard is a desirable objective in itself. It makes nurses better equipped to address the ever increasing sophistication, both in treatment techniques and in equipment, and crucially it gives student nurses who are so motivated the chance to aspire to management positions within healthcare.
The downside of this, to which the noble Baroness has referred, is that during this period of nurse training a decreasing amount of time is spent on the ward with hands-on experience of dealing with patients. This is compounded by the fact that there is not the same opportunity for the junior nurse to learn from the ward sister—who I suppose one must now refer to as the ward manager—who can pass on his or her experience. These individuals so often find that the nursing teaching posts are more attractive than hands-on nursing and it is to these that many of them move. This is a problem which is not going to go away; frankly I see no immediate solution and I should welcome comforting words from the Minister.
I have some recent experience of the healthcare sector as a former chairman of an independent hospital in London, the Hospital of St John and St Elizabeth. On the whole, the independent hospitals have been able to retain the traditional system of the matron having total responsibility for the nursing staff, with the ward sister or manager looking after patients on the ward and, crucially, having responsibility for services such as cleaning. It would be both arrogant and unrealistic, coming from the independent angle, to say “If we can do it so can you”. There are so many differences between the environments of the National Health Service and the independent sector that it makes such a glib suggestion inappropriate, not least the organisational demands which a body the size of the National Health Service faces. Furthermore, on a personal note, I wish to place on record the great help and support the hospital with which I was associated receives from the NHS in many, many ways. There should be no misunderstanding about this—I am not referring to financial help. However, it is important that the two sectors have regard for each other, possibly to their mutual benefit.
Let me recount one experience I had which I think may be relevant to this debate. While the independent sector struggles to attract good nursing staff as much as the NHS, most are fortunate in having a satisfactory body of trained nursing staff. However, many of these hospitals, including my own, also operate a programme of giving work experience to trainee nurses in the NHS. Ours formerly involved an arrangement with one newish university in the London area. On more than one occasion, Matron was somewhat startled to come across the attitude “I am not interested in the nursing, I am only here to get something on my CV”. Subsequently—and understandably— the change was made to sourcing from one of the London teaching hospitals where we encountered a totally different type of student nurse—keen and committed, potentially a credit to the nursing profession.
The wastage of resources in the nursing training programmes of some institutions is self-evident and I would welcome an assurance from the Minister that his colleagues in the DoH are monitoring this, and particularly the suitability of candidates for these training schemes. My message to your Lordships—and, indeed, the Minister—is that I see no easy, quick-fix solution to the present less-than-perfect juxtaposition between academia and ward experience.
In conclusion, perhaps I may return briefly to the subject of ward cleaning. Many are the complaints one hears that the ward was dirty and that the ward manager was unable to do anything about it because he or she was not in the reporting line for the contractor. I hope that arrangements can be made in future contracts for the contractor to be more visibly responsible to the ward manager. That would go some way towards allaying this problem, which seems too dependent on considerations of cost.
Baroness Warwick of Undercliffe
My Lords, I thank the noble Baroness, Lady Emerton, for providing this opportunity to highlight this crucial aspect of our national healthcare provision. Her distinguished leadership and experience in the nursing field give enormous weight to her observations today. She is a doughty advocate for the nursing profession.
There cannot be anyone in this House who has not at one time or another had cause to be grateful for excellent nursing care. However, we may also know of, or have experienced, less than compassionate care, or even neglect or indifference, from overstretched nursing staff. Like others, I am horrified by some of the stories that have appeared in the media, and we cannot ignore the shocking failings uncovered, for example, at the Mid-Staffordshire NHS Trust. Sadly, it would be wrong to suggest that the unfortunate cases that hit the headlines are entirely anomalous or isolated incidents. Indeed, it seems that not a week goes by without another story revealing a lack of care and compassion and arguing that standards are falling.
Some of those who claim this most vociferously blame the lack of compassion on the move to make nursing a degree-level profession. Like the noble Viscount, Lord Bridgeman, I want to focus my remarks on the area of nurse education. I want to challenge most strongly the line put forward in the media—and, indeed, on occasion in this House—that some of the recent instances of lack of care are because nurses are now all graduates and consider it beneath them to clean bedpans or clean after the vulnerable and sick in their care. The “too posh to wash” arguments favoured by newspaper columnists do not stand up.
Studies in England, Scotland and Northern Ireland have shown that graduate nurses spend longer hours working in clinical areas than their non-graduate counterparts. American studies have found that graduate nurses stay in the profession, on average, four years longer than non-graduates and, in addition, they tend to stay at the bedside more often, working with older people and those who are terminally ill. US research—it is a shame to quote only US research but there is very little research in this country on this area—has also noted that graduate nurses acted more independently and took more responsibility for their professional judgment.
The point I wish to make is that there is not, and should not be, a distinction between professional academic head on the one hand, and caring heart on the other. As the excellent report, Front Line Care, asserted last year:
“Truly compassionate care is skilled, competent, value-based care that respects individual dignity. Its delivery requires the highest levels of skill and professionalism”.
The core values of care and compassion do not change even as nursing becomes more demanding and complex. The challenges that nurses face today require higher degrees of skill and a more well-rounded preparation. Indeed, Front Line Care urges:
“To ensure high quality, compassionate care, the move to degree-level registration for all newly qualified nurses must be implemented in full … There must be greater investment in continuing professional development.”
I strongly support this position and I hope that the Minister, in replying, will confirm that the Government do too. Nurses practise in increasingly complex clinical and social environments.
The decision in 2009 that all new nurses must hold a degree-level qualification to enter the profession from 2013, was made with the aim of increasing skills, and training a medical workforce capable of operating in a more analytical and independent manner. I believe that making nursing a degree-level profession is the way to ensure high-quality front-line patient care. Currently, one in four nurses has a degree as their highest qualification, and I believe this must grow. As the noble Baroness, Lady Emerton, reminded us, this would merely enable us to catch up with Wales and Scotland and several countries in Europe and elsewhere—indeed, as well as with other professions.
I believe that it is a mistake to view being academically qualified and being a caring professional as somehow incongruous. This is not assumed in medicine or clinical psychology, so why should it be in nursing? Compassion is vital, but it is not enough; nurses must also be well educated to deliver safe, effective care. All nurses need to put quality care at the centre of what they do, but they also need extensive knowledge, analytical skills and experience to work in a variety of settings.
I know that universities strive to ensure that students entering the profession have the right blend of personal, caring attitudes along with the necessary knowledge and practical skills to deliver high-quality, evidenced-based nursing care for patients. This is why, as the noble Baroness reminded us, half of university-based education programmes at both degree and sub-degree level continue to be delivered on the ground, in health practice. Of course, there can always be improvements, and I know that universities and hospitals themselves are striving to make those improvements. But education and training must not stop at the point of registration. It must continue to consider post-qualification pathways for recently registered nurses, and recognise the importance of both multi-professional training and continued professional development.
Many noble Lords have raised the importance of education and training in a reformed NHS as the Health and Social Care Bill goes through Committee, and we have been reassured that the Government will give this area due weight and consideration on Report. Will the Minister reassure us today that, in its plans in the Bill for ensuring the continuation of appropriate education and training across the health professions, and developing a well educated and compassionate workforce, the new system will ensure continued professional development?
My final point is to echo some of the points made by the noble Baroness, Lady Emerton, that front-line nursing care is being severely threatened by the £20 billion efficiency savings target set by the NHS. The Royal College of Nursing's Frontline First campaign has been monitoring cuts in NHS services and posts since July 2010. Its analysis of 41 trusts in England has highlighted the fact that registered nurses and healthcare assistants account for 34 per cent of the posts earmarked to be cut. On average across the 41 trusts, 8.3 per cent of qualified nursing jobs appear to be lost. The RCN cites these findings as evidence that trusts in England are making short-term cuts to meet the efficiency savings target. So, despite Government promises that there would be no cuts to front-line NHS care, clinical services and staffing levels are indeed being severely affected. At the same time, we know that English SHAs are cutting the number of pre-registration nursing places they fund. Last week, it was reported that nursing courses in London would be reduced from 2,000 to 1,580 after NHS London decided to withdraw funding. Estimates earlier this year suggested that course places in England for 2011-12 would be cut by 9.4 per cent compared to the previous year. These cuts to existing posts and to new entrants will have potentially disastrous consequences for patient care. So it is important for the Minister to address the issues of cuts and places in his reply.
The need to provide skilled care for people with many different conditions will continue to grow; we must have sufficient nurses, and our nurses must be properly equipped and supported to provide that skilled care.
Baroness Jolly
My Lords, I thank the noble Baroness, Lady Emerton, for inspiring this debate. Hers is one of the most respected voices in your Lordships’ House, and when she speaks on this subject we all listen and learn. I am also delighted to see here in the Public Gallery nurses who have come to listen to the debate.
What is the front line? All but a few of the 600,000-odd nurses are working right there, delivering world-class care to their patients. Some will be in key management positions in our trusts and a few are top civil servants advising the department and strategic health authorities. They are members of clinical networks, and I hope that in the new world they will be advising the NHS boards and should be on clinical senates.
If you were to talk to a focus group of the general public and ask them to close their eyes and think of a nurse, what would they say? In all probability they would think of a woman. Depending on their age, they might put that nurse in a frilly starched cap, and almost certainly in a hospital at the sharp end of acute medicine—including theatre, A&E, intensive care and neonatal nursing—although those with recent experience of the NHS might have a more modern, nuanced view. Of course, that picture is not accurate. Many nurses are men, and in the days of infection control frilly caps have gone. This focus group might be surprised that it is a graduate profession and that there are many specialist nurses with the equivalent of masters’ degrees in their specialism. This situation is completely unrecognisable from that of 20 years ago. Let us be completely clear—here I totally agree with the noble Baroness, Lady Warwick—that, despite much red-top protestations to the contrary, all but a very few nurses do their jobs with utmost professionalism, as they fit into a multidisciplinary team based around patient care.
I shall focus my remarks today on the nurses whose front line is the local community and who work in community settings, in the home and in community hospitals. They are largely unsung but play a vital role in patient care. They give the patients what they want—personal care at home or close to home. Their role is vital in keeping patients out of the acute setting wherever possible and in taking tasks from doctors, who are thus freed up for diagnostic work. We should be in no doubt that this is not only good news for the patient but, incidentally, delivers considerable savings to the NHS.
What roles might nurses take in community care? They are involved with cancer, continence, COPD, diabetes, district and community nursing, end-of-life care, learning disability, mental health, midwifery, minor injury nursing, multiple sclerosis, older people, practice nursing, prescribing, renal, school nursing, smoking cessation, stroke and substance misuse. My list is not exhaustive, and I apologise unreservedly for any areas that I have omitted. These nurses are quietly innovative. The way that they work improves the care of their patients. They are collaborative and forge links with GPs, acute care, charitable sector providers and local authorities. They were designing informal packages of care and pathways before those terms were in common parlance. They act, while others plan and strategise.
In the history of community specialist nurses, midwives get the earliest mention in literature, in Exodus, delivering babies as the tribes of Israel fled from Egypt—if anyone can go back more than 6,000 years, I am happy to hear of it. This is a far cry from the world that my noble friend Lady Cumberlege spoke about on Monday in Committee on the Health and Social Care Bill. I should like to highlight two areas of outstanding care. Your Lordships will know that I worked for Macmillan Cancer Support, and I should like to explain its work in the community, and the role of minor injury nurses.
Last Sunday, I attended a service in Exeter cathedral to celebrate 100 years of Macmillan Cancer Support, which was established by Douglas Macmillan in response to his father’s death from cancer. There are now thousands of Macmillan-trained nurses in the community, offering services such as chemotherapy at home, wherever possible, and helping the whole family deal with end of life, where necessary. At present, only a quarter of patients are able to die in their own beds, and 24/7 community nursing is critical to helping cancer patients die at home. These front-line nurses prevent crisis situations from occurring, so that patients are not transferred into hospital and hence reduce costs to the NHS in the longer term. However, half of PCTs are not providing this vital service. The palliative care funding review recognised that a relatively small investment in 24/7 community services would enable commissioners to deliver improved outcomes for patients and ensure that palliative and end-of-life care services are delivered in the most cost-effective way. The new draft end-of-life care quality standard also supports the need for 24/7 community nursing, and Macmillan would like to see the standard implemented effectively and as quickly as possible. Macmillan is also supporting those living beyond cancer. Macmillan nurses help families link into specialist benefits advisers—either Macmillan's own or those trained by Macmillan and now working in CABs across the country—who work through and around the system for the patient and their carers. That is true personalisation.
On minor injury nurses, every week millions of people go to A&E or their own doctor for conditions that are minor—neither an accident nor an emergency. They go because A&E is easily accessible, but they waste the time of trauma teams. Two highly skilled specialist nurses in a community hospital or within an A&E department can run a minor injuries unit. They have access to advice from the A&E department as and when required. These units are able to treat a range of conditions: cuts, bruises, burns, simple fractures —even broken bones, as long as the skin has not been broken and the bone does not stick through—as well as sprains, strains and head injuries. Saturday afternoons see them full of sportsmen and women. In one year in Cornwall, 900,000 patients attended a Cornish minor injury unit. This prevented nearly 1 million attendances at A&E. By anyone's reckoning, that is an impressive record. If we visit their websites, praise for their service is fulsome. Holiday-makers visiting Cornwall, in Newquay, St Ives or Bude, leave messages on the websites to say how impressed they are by the services and asking why they are not offered locally.
I would like to move on to two general points about specialist nursing. Changes to the workforce need to be patient-centred and must not be undertaken simply as a cost-cutting exercise. There is anecdotal evidence that, in some cases, services are downgrading roles simply to save money without analysing the needs of patients. Changes to the workforce need to be thought out and patient-centred, mapping needs against skills. Macmillan is looking at how cancer patients can be given one-to-one support by a team of different professionals so that they receive support from the right person at the right time. In particular, Macmillan is looking at how support workers can be used to release capacity for specialists so that they can concentrate on tasks that make best use of and develop their skills, thereby improving the productivity and efficiency of teams.
I would like to echo remarks made by the noble Baroness, Lady Emerton, the noble Viscount, Lord Bridgeman, and the noble Baroness, Lady Warwick. I suspect that the speakers who follow might agree, although I dare not anticipate your Lordships’ speeches. Education and training must be protected if we are to ensure a high-quality future nursing workforce. I am extremely concerned that under the current financial constraints, education and training budgets are being cut. In addition, there is not the capacity or funding to free up professionals to attend such training. Neglecting the continued education of professionals hampers their ability to advance their knowledge to meet the new and emerging needs of patients and threatens the future supply of specialist nurses. I would welcome assurance from the Minister on this subject.
This has been a very interesting and important debate. Its timing within the Committee stage of the Health and Social Care Bill is really useful. We must do all we can to advance the nursing profession and in particular those specialist nurses who add so much to patient care.
Baroness Masham of Ilton
My Lords, I thank my noble friend Lady Emerton for securing this debate on front-line nursing care. Whatever health Bill comes before us as new legislation, nothing will improve unless caring, compassion and dedication are put back into nursing. There is a lack of leadership and the lack of anyone taking responsibility on some wards, which are understaffed and badly managed. If there was a referendum on whether to bring back the old-type matron, who was in charge of nursing within the whole hospital and sisters who were hands-on and in charge of their wards—and the cleaning and helping of patients with their problems and discharge—wards would be better run.
Many of the tiers of nursing administration should be dropped; I am sure that the public would agree overwhelmingly. It is leadership and responsibility that is needed with front-line nurses. There is no doubt that hospitals are challenging places to run and that good administrators are vital but, again, there should not be overload and they should not be in conflict with clinical staff. The safety and well-being of patients should be the priority, and working in harmony is surely better. A consultant told me the other day that she had gone to the ward to see a patient and asked a nurse for the notes. The nurse retorted that the patient's nurse was not there that day, so I ask: was no one looking after her? This attitude is so unhelpful and the culture needs changing.
The other day, I was telephoned by a very popular GP who retired last year but still trains doctors. He told me that one of his trainees had a very rare condition that needed a life-saving operation, but the funding was not forthcoming. It is becoming a desperate situation. Knowing that his wife nursed part time in the local hospital, I asked how she was. The answer came back that she had become so concerned about patient care and nurses going off sick that she had not been sleeping at night, and had worried so much that she has now left. This nurse was Guy’s trained and could not go along with the lack of staff and poor standards. It was one of the good days for patients when she was on duty. A culture of indifference to patients seems to have crept in with many nurses.
Having said that, I know that there are some excellent nurses and, for anyone who appreciates good nursing, they shine like bright stars. This being World Aids Day, there will be a debate on HIV and AIDS later today, and I have been so pleased to meet some very dedicated and kind nurses working on wards with AIDS patients. Perhaps this is because they have chosen this specialty and it is more than just a job. This is also the centenary year of Macmillan nursing—many congratulations to that splendid organisation, which has about 5,000 specialist nurses throughout the country, helping and advising people with cancer, while volunteers raise money by all sorts of ways. For many long-term conditions, specialist nurses are vital for illnesses such as diabetes, Parkinson’s disease, stroke, epilepsy and so many other conditions. They teach patients and carers, help patients from getting worse and keep them out of hospital. They are the vital link between primary and secondary care.
Most importantly, however, there are cuts to nurses, including those qualified in specialised neonatal care, and this cannot go on. There is a serious situation at the moment because the £20 billion Nicholson efficiency savings are causing cuts in important front-line nursing staff. For example, when nurses retire they are not being replaced. It has been brought to my attention that there is considerable anecdotal evidence that demonstrates how the district nursing service has been stretched to the point that it is providing a bare minimum service in many areas. District nurses are vital if patients who need nursing care in the community are to manage. The importance of district nurses should be recognised. Skills needed for nursing in the home are different from other forms of primary care nursing. I hope that the Minister will look into what is happening across the country.
With all the recent reports about the lack of care for the frail and elderly, and the horrific evidence shown in the “Panorama” programme of cruelty to people with learning difficulties in a care home, it seems that care assistants should be registered and regulated. I am among many people who feel that it is of great concern that nurses can be struck off their register and take unregistered jobs as care assistants. Patients are being put at risk, as it is unrealistic to think that the few nurses on a busy ward can supervise both care assistants and student nurses when there are vital jobs that only the nurse can do behind closed curtains. There should be training for all care assistants. They are often dressed up in uniforms which are indistinguishable from trained nurses, which is not open and honest to patients.
On a positive note, I would like to say what an excellent job nurses do in front-line nursing in Afghanistan. There seems to be real team co-operation while working under stressful conditions.
Prevention of infection has become more important than ever, given the increasing resistance to antibiotics. I would like your Lordships to realise the importance of infection control nurses working on the front line. There is much concern about moving the Health Protection Agency, which is vital in the fight against infections. Any dilution of its independence and ability to research will have an effect on front-line nurses in the long run. There are many infections, such as gram-negative bacteria, klebsiella and E. coli that affect urinary infections as well as PVL-SA—Panton-Valentine leukocidin positive staphylococcus aureus—which is an infection that can affect young, healthy people, causing necrotising pneumonia and can kill in a few days. There have been improvements in MRSA and C. difficile in hospitals, but controlling infections needs constant attention to detail. We should never get complacent.
I have great admiration for the front-line nurses who go out and find homeless and hard-to-reach people at risk of tuberculosis and work in prisons with a multitude of infections, including hepatitis B and C. Drug-resistant TB must be kept under control. These resistant infections, which are expensive and hard to treat, can be passed to anyone. Without doubt, front-line nurses are vital for our well-being and that of our children. They vaccinate the population and so often are the first people to stop a killer infection such as meningitis in an A&E department.
I hope that this debate will help to show our appreciation for front-line nurses, who need to have the highest standards to keep the NHS on top of the job.
Lord Hunt of Kings Heath
My Lords, in thanking the noble Baroness, Lady Emerton, for her splendid opening to our debate, I declare an interest as chair of the Heart of England NHS Trust and as a consultant and trainer for Cumberlege Connections. I also acknowledge my noble friend Lord MacKenzie on the Front Bench. I suspect that what he does not know about nursing is not worth knowing; it is very good to see him there.
This is a very timely debate. We all agree that the quality of nursing care is fundamental to the quality of the patient experience. However, we are presented with a paradox. On the one hand there have been huge advances in the nursing profession over the past 20 years. There has been the move to it being a graduate profession. Nurses have taken on much greater responsibility. There is complex care and specialist nurses, in both hospital and the community, as the noble Baroness, Lady Jolly, so vividly informed us. I think also of midwifery. If the noble Baroness, Lady Cumberlege, were here, she would be able to talk about changing childbirth and how the profession was encouraged to take on a huge leadership role. The public have welcomed the increased responsibility that nurses have taken on.
At the same time there has been a mounting concern about basic standards of care and issues to do with hygiene, the feeding of patients, nutrition, dignity and even face-to face contact. This has been reinforced by several reports from unannounced visits and the CQC over the past few years. There have been any number of investigations of concerns about what seems to be a falling off in basic values of care. What is the reason for that? My noble friend Lady Warwick convincingly demonstrated that the old canard about modern nurses being “too posh to wash” just does not stack up. However, there are a number of questions that one might ask. There is a real question about whether nurse training is too focused on academic performance rather than on practical nurse training.
I also wonder whether the drive for specialist nurses and modern matrons has removed too many experienced nurses from the ward or the equivalent within the community. Has the lack of regulation for healthcare assistants led to patchy and inadequate care in some places, despite the undoubted dedication of many of them? We need some serious thinking about how to enhance quality overall and the standards of basic care that nurses give. Certainly, in my own trust a lot of thinking has gone into the quality of nurses. I claim no credit for it. While we do not have matrons in starched caps, we certainly have visible chief nurses in purple uniforms walking the wards as a visible demonstration of nurse leadership, which has been warmly welcomed. Anyone who wants to see nurses really dressed up should go to the Florence Nightingale service in Westminster Abbey once a year. I always hope that the chief nursing officer will come in uniform—alas not. To see the chief nurses of the Army, Navy and Air Force marching up the aisle is a wonder to behold. The reason why the public like to see it is that they want to see nurses in authority. They want them to have the confidence to be leaders in the ward, in the community and in the health service as a whole.
Another thing that we have done is to develop a robust measurement of nurse standards by polling 400 patients a month, looking at the results, reporting to the board and trying to identify any problems with nursing care. The third thing that we have done is to develop VITAL—virtual interactive teaching and learning. Essentially, it assesses all nurses online for their knowledge of best practice in fundamental care. This covers, for example, nutrition, falls, privacy and dignity and pain management. Since the summer, 60 per cent of our trust’s workforce have achieved 100 per cent in that online examination. Our intention is that from next year all newly qualified nurses and midwives will have to achieve 100 per cent within six months or they will not get the substantive contract. We also expect our nurses and midwives to sign up to a code of values and behaviour. We are introducing a badge for our nurses which will be achieved only if they get 100 per cent in the online test, sign up to our values and have evidence that they are putting those values into action. The noble Baroness, Lady Emerton, will certainly remember the badge, which nurses wore with pride. It showed where they came from and who they were; for example, the Tommy’s nurses. We need to get some of that ethos back into the health service.
We have done a lot but there are a lot of issues around the training and education of nurses. I do not disagree with the requirement for nurses to have a degree. I do not think there is any argument about that. However, we have thought about how a foundation trust could be much more involved in nurse education and in supporting students in practical nurse training. We wanted to facilitate a practice-based model built around the trust which promoted our core values but adhered to national standards and the curriculum as laid down by the Nursing and Midwifery Council and with appropriate academic accreditation. It is fair to say that our proposal has not met with universal acclaim. Indeed, I feel that all the establishment bodies concerned with nurse training and education have put a real dampener on this. We have been accused of turning the clock back to the old schools of nursing. That is a bit unfair to some of the old schools of nursing because they were pretty good. However, we are not trying to do that. We seek to facilitate a more practical-based nurse education degree, which would have degree status but would be built much more around the hospital and its values. I do not think that this discussion is at an end. I believe that we will soon have a new chief nursing officer to follow on the excellent current CNO Christine Beasley, if one has not yet been appointed. This must be one of the main focuses of the new chief nursing officer. What could be more important than sorting out the education and training of nurses?
The noble Viscount, Lord Bridgeman, and the noble Baronesses, Lady Jolly and Lady Masham, were right about the role of senior sisters, or their equivalent, in the community. We need to empower them to lead. That means they have to have control of the budget so that whoever is providing the cleaning or the food, whether it is directly employed people or contract cleaners, none the less when the senior sister wants something to happen there is no question but that it happens. We need to give our senior sisters much more confidence and support to take on a leadership role. We need to go back to the days when doctors were a bit scared of the senior sister because she is in charge and she is the person on whom the patients depend for the overall quality of care. Making our senior sisters supernumerary so that they can focus entirely on leadership and management will cost us £1.6 million. It is a challenge to find the resource to allow them to focus much more on leadership. The problem with being drawn back into being counted as one of the qualified nurses on wards is that they then get so focused on caring for patients that they just do not have the time to carry out the leadership role that is required.
I urge the noble Earl to take account of two further points. My noble friend Lady Warwick talked about the lack of UK research in relation to basic nursing standards. The noble Earl will not be surprised to hear that there is an issue with regard to the amount of money spent on research into nursing. I know of the efforts made by the department over the years to give a boost to the amount of money spent on research in relation to nursing but clearly we need to go somewhat further in that regard. We probably need to have more academics who can focus on research.
With regard to healthcare assistant regulation, the Government’s response is to have a voluntary register. I suspect that there will be a halfway house and that it will not be long before some NHS organisations will say, “You can’t be a healthcare assistant with us unless you register voluntarily”. I hope that training programmes will be set up but, for the reasons that the noble Baroness, Lady Masham, has given in terms of safeguarding the public, the argument for regulation is becoming ever more persuasive.
I hope the noble Earl recognises that the number of nurse training places should be determined by Ministers. If he devolves that issue, he will find that in times of financial difficulty the number of training places will be cut. I would give much more discretion to the NHS locally to determine arrangements with universities regarding the provision of graduate education for nurses. However, history tells us that the moment the department relinquishes control of the number of training places, the health service does the wrong thing. I know that we are debating the tension between national leadership and local discretion, but national leadership is required in some areas, and this is one of them.
Baroness Browning
My Lords, it is a great pleasure to follow the noble Lord, Lord Hunt of Kings Heath, with whom I have debated many issues in this Chamber.
I agreed with every single word that he said in this debate. I stand in awe of what he has done in his trust. He recounted the list of things that had been implemented, not all of which seemed to need an awful lot of money, although I understand what he said about education and training. You wonder why such practice cannot be rolled out around the country and why exemplars cannot be picked up rather than having trusts that try to reinvent the wheel, struggle or in some cases attract rather adverse headlines, as we have seen in recent years.
I had the great privilege to serve as a Member of Parliament for 18 years in another place. During that time I had the pleasure of working with and for nurses and midwives in my constituency, many of whom came to see me to discuss the problems that they encountered in their work. Sometimes they came individually and sometimes collectively. I pay tribute to the work that the profession does. There are people out there who go that extra mile. As patients or relatives of patients, we should all be extremely grateful to them for that. I know that I am.
However, as has been mentioned by other speakers, healthcare, which includes the nursing profession, has been the subject of some very worrying and adverse headlines, not just in recent weeks but for a long time. Some eight years ago in a debate in another place I raised concerns about nutrition and fluid intakes based on my personal experience of having an elderly relative in a hospital. It seems to me that these things have gone on for a very long time. Mencap still has concerns in this regard. Three years ago it published a report, Death by Indifference, which discussed people with learning disabilities who had died on hospital wards not through disease but through neglect. That is an indictment of us as politicians and of our nation. Members of the nursing profession and others involved in healthcare must feel that very keenly when they see and read about what is happening.
As I listened to the noble Lord, Lord Hunt of Kings Heath, I wondered how hard it would be to make best practice universal if there was a political will and a professional will in all parts of healthcare to look at what works and to implement best practice. I realise that budgets come into these things and that there are always differing opinions on how to do things. However, we are starting to see some common themes coming through, not least in the report Front Line Care, which the noble Baroness discussed. There is a common theme in this report. There is great confusion in the healthcare system, particularly in hospitals, and we as patients are also confused. It is quite possible to go into a general hospital ward and come away still not really knowing who was in charge. It is the uniforms, it is the way people conduct themselves. It is not that people are not doing their job, but you cannot always say who is in charge.
The heading on page 60 of the report says, “The Proliferation of Roles and Titles”, and I would add uniforms to that. At one time I thought I understood all the uniforms on a ward, but I have to say that I do not now. Having been in hospital this year, all I can say is that the lady in the pale blue uniform did a jolly good job for me, but I still do not know what her job title was. The report says:
“especially doctors … were often unclear about what skills and competencies they could expect from individual nurses and support workers, exacerbated by the plethora of job titles and role descriptions”.
It is bad enough that I as a patient was confused, but the fact that doctors are also confused tells us that something needs to be sorted out, and urgently.
Much more seriously, if doctors do not know what they can expect from these different job titles and uniforms, and if the nurses themselves have to delegate—I will come on to delegation in a moment—it is no wonder that there are problems and that some of them become systemic. I say to my noble friend, for whom I have great respect for the work he does on the Front Bench, that these problems are now systemic and need to be treated as a matter of urgency.
Frankly, we do not need another five years of reports and anecdotal evidence. It seems pretty obvious that some people are now overcoming these problems—the noble Lord, Lord Hunt, explained what happens in his trust—and this could now be rolled out. While I understand the need for localism and local decision-making, the Government have to take some leadership in making sure that this is rolled out and that they act as the catalyst to ensure we do not have the same debate in five years’ time.
I return to the subject of nurses and the nursing profession. I agree with noble Lords who have said that it does not necessarily follow that because someone has a degree in nursing, they lack compassion. That is a rather terrible thing to say. However, there is a question about the structure of nursing, which yet again is picked up very well in the report on page 87, under the part entitled “The Way Forward”. The report says:
“There was much comment on the style of leadership needed for the future. ‘It’s to do with whether we’re transactional (you will do this, that or the other—talking down to staff)”—
the Hattie Jacques scenario, I suspect, although a lot of people would quite like to see a few more Hattie Jacques on the ward—
“or transformational leaders (embracing staff and recognizing skills and contributions)’”.
The report goes on to talk about mutual respect, not working in silos, and working as a team. Anyone who has worked in any large structure, whether in healthcare or elsewhere, will recognise those two different styles of management, although I have to say that it does not have to be one or the other. Leadership is about taking difficult decisions and about looking holistically across the whole. I quite agree with colleagues who have said today that those in charge of a ward should also have the authority to deal with nutrition and cleaning. I remember a debate in a German hospital, where the wards were absolutely spotless, about whether cleaning services should be contracted out. The question was asked, “How do you make sure that these wards are so absolutely spotless?”. The reply was that the cleaning was contracted out but that the person in charge of the ward was able to stop the payment of the contract if they were unhappy with the results. That is the sort of authority and leadership that is needed on a ward, and it should be placed with an individual. This is not rocket science. If we had the collective will to implement that, it could be done tomorrow.
Nurses also have to delegate. I was very interested to hear Tony Hazell giving evidence on Tuesday to the Health Committee, which is holding an inquiry into education, training, and workforce planning. He said that there will be more training, both for nurses and for healthcare workers to whom nurses delegate. From this report, it is clearly rather important that everyone in the structure knows and understands their role, and that people are prepared to delegate so that they are not working in silos. In-service training is also important for nurses working in hospitals, out in the community and elsewhere, as well as for those who are not nurses but who work in a supportive role. If such ongoing training were in place, we would not get the horrendous stories, which I have personally experienced on more than one occasion and with more than one person, of food being left at the end of the bed for someone who cannot access it. In-service training and education throughout is important, and it will also help nurses.
Finally, it is important that where there are serious problems, nurses should be able to report colleagues in a structured way. It is called whistleblowing—a horrible term—but in my experience, where really good nurses experience this and hit the buffers in trying to report problems, too many of them leave the service. They find it just too difficult and too unpleasant. We have to build that into the structure when we come to reform these services.
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.
Lord Patel
My Lords, I note that I am the only doctor speaking in this debate. Noble Lords are right: doctors do as matrons tell them. Therefore, when my noble friend Lady Emerton—the matron—said to me, “You will speak”, I did not argue, but I am very pleased to be able to do so and I thank her for the opportunity.
As most noble Lords know, during my fruitful life my specialty was maternal foetal medicine. I worked in a team that looked after mothers whose pregnancies were complicated by other medical conditions or who developed serious complications during pregnancy or labour. I pay tribute to the most dedicated nursing workforce with whom I had the privilege to work—midwives and specialist neonatal nurses. They were the key members of the team and prevented not only deaths but handicaps among the babies who were born either prematurely or with difficulties, or whose mothers had a difficult labour. They are the most skilful nurses with whom I have ever worked. I still go to my hospital occasionally. I walk through the labour and delivery room and get the usual comment: “Have you come here to work or to drink our coffee?”. I have the coffee, as I do not think that I would be allowed to work. I am going to talk mostly about the current state of affairs in midwifery and neonatal nursing.
We currently have a shortfall in England of between 4,500 and 5,000 midwives. This is partly because of a fall in recruitment but it is also related to an increase of 22 per cent in the number of live births over the past two years. There are now 690,000 births per year in England. Another problem is that the midwifery workforce is ageing. Half the workforce is aged between 45 and 55, and therefore recruiting a younger workforce is extremely important. Not only that, there is a change in the way in which midwives work. Their work has become more complex because of older mothers. There has been a 71 per cent increase in 40 year-old mothers and a 24 per cent incidence of obesity in pregnancy, both of which lead to higher rates of complications in antenatal care and in labour.
There is also a reduction in the overall budget. In 1997-98, the maternity services budget was 3.1 per cent of the total NHS budget. Although the sum might have gone up in total, it was 2.46 per cent in 2010. There is a serious issue of recruitment of midwives and an increase in maternity services. I know that the Government recognise the problem. Even before the election the Prime Minister, as Leader of the Opposition, writing in the Sun pointed out that midwives were,
“stretched to breaking point … overworked and demoralised”.
He promised that when in power, the Government would increase the number of midwives by 3,000. Unfortunately, that has not happened.
I congratulate the Government on the issue of training. They have committed to maintaining the same number of places for student midwives in the 2011-12 academic year as there were in 2010-11, which was a record high. This is welcome as it will help to address the two issues of the midwifery shortfall and the ageing midwifery profession, provided that there are jobs at the other end of the process. Recruitment ought to be part of it.
Last week the Royal College of Midwives published its State of Maternity Services Report 2011, which makes several good points. The key ones suggest steps to address the problem. One is to increase the choice of place of birth—I know that the Government are keen to allow mothers to have a choice—such as midwifery-led units and home births. Births in these settings require less midwife time, and in low-risk pregnancies outcomes are not affected. Other suggestions include: the appropriate deployment of properly trained and supervised maternity support workers to do non-midwifery tasks; a guarantee not to cut midwife training places; and encouraging the health service to increase recruitment and meet the target of 4,000 more midwifes.
There is clear support for more midwives. A recent public e-petition to Parliament calling for the Government to recruit an extra 5,000 midwives has already been backed by 20,000 people. I hope that after today’s debate it might increase to 2 million. I hope that I have made my point that there is a need to address the midwife shortage if we are to deliver quality care to pregnant mothers and newborns.
I turn briefly to the issue of neonatal nursing. As highlighted in the report published on 9 November by Bliss, a special-care baby charity, one-third of neonatal units in England are cutting their nursing workforce, stopping recruitment or downgrading posts. Referenced against the Department of Health’s toolkit for neonatal services, there is a shortage of nearly 1,200 neonatal nurses. Care of the neonates, both premature and following neonatal surgery, is highly skilled, intensive work, and outcomes for those vulnerable babies, including mortality rates, are directly related to skilled nursing care around the clock. Cuts in training and education budgets have led to a shortage of qualified specialist neonatal nurses. We need commissioners and providers to implement NICE specialist neonatal care quality standards. In future we will rely a lot more on NICE quality standards to drive up quality and outcomes in the health service. If they are not implemented—as they clearly are not, in specialist neonatal care— improvements will not come about.
The Government want a reduction in perinatal and infant mortality. Delivering care to neonatal quality standards will go a long way to achieving that. I look forward to the Minister’s comments on both maternity and neonatal services.
Lord Ribeiro
My Lords, I apologise for speaking in the gap without giving notice, but I could not let the noble Lord, Lord Patel, give the impression that he was the only doctor here who was prepared to speak. I thought that I would share some thoughts on my view of nursing, which I have to limit to my own special interests of surgery as they are the only group of nurses I know anything about.
It is interesting that reference was made to the Salmon report, which I think was produced in 1968 when I was a fairly young junior doctor in the Middlesex hospital, which sadly no longer exits. We had a matron, wing sisters and ward sisters, and there was no question about who was in charge. There was leadership right down to the ward level, and the important thing about nurses at that time—there are still quite a few of them out there today—was that they knew they were in charge. They had responsibility for the ward and I totally agree that we should not wait for the hospital manager to say that a sister of a ward cannot tell the cleaning staff that they have to stop. I well remember doing ward rounds at Basildon hospital when the sister would put a notice on the door saying, “Ward round in progress. Consultant present. Quiet please”. If the cleaning staff tried to come in she would tell them to go away until the ward round was finished. Latterly we would not dare tell the cleaning staff to go away because their response would be, “If I don’t clean this ward now I’m not coming back”. There has to be proper leadership. It does not have to come from Richmond House; it has to come from within the organisation, seeing its responsibility to ensure that leadership is delivered. Leadership is the key—knowing who is in charge.
One of the things that has been said about doctors is that they have treated nurses as their handmaidens. It may be said that doctors have been resistant to seeing nurses progress, and we have had a long debate about training, education and diplomas, which I shall not go into. But the opportunities that opened up for nurses after Salmon did provide nurses with a way to move into management and other areas. The advantage for nurses is that their opinion and advice has influenced medical care over the past 40 years that I have been in medicine, and much of it to the good. The downside has been that we have created another pathway for nurses to go other than the ward. Therefore, talented nurses may have wanted to stay on the ward but if they wished to progress and improve their salary status, they had to go sideways into management. That is where some of the problem has emanated from. We must look at ways of remunerating and keeping nurses who want to stay on the wards to do so.
I shall not speak for long but I want also to make a point about teamwork—nurses and their contribution to the team function. As a surgeon, like the noble Lord, Lord Patel, I know that we work in a close team. Our main team is the ward staff and ward sister who look after our patients. In my case the ward sister would tell me through the grapevine when my junior doctors were not doing all that they should. There is a big function for the ward sister, other than just looking after patients. In theatre, you have a close-knit team. Another thing that I regret is that in the old days many nurses would come along and observe what was going on in theatre and say that they would like to become theatre sisters. They were encouraged to go into it. Latterly in my time as a consultant, I found that fewer and fewer nurses were being directed to go to work in theatre. I think this is a great shame because we live in a world of multidisciplinary working, and it is important that nurses should be encouraged to specialise if they wish to.
Finally, I came back from Afghanistan recently, and in answer to the noble Baroness, Lady Masham, I have to say that the nursing teams in Camp Bastian are superb. Many of them are volunteers from this country, and their contribution to the war effort in Afghanistan has to be noted and applauded.
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.
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.
Baroness Emerton
My Lords, I thank every single person who has contributed to this debate, which has covered a very wide area. Everything said was neither good nor bad, but was to be noted—as the title of the debate invited us to do. The debate has given us an opportunity, particularly as we are in the middle of the Health and Social Care Bill, to ponder on some of the things that have been raised today. It has been particularly open and honest, and I congratulate and thank everyone who has participated. It has been an especial pleasure to me to have in the noble Lord, Lord MacKenzie, a nurse on the Front Bench and I thank him for it. I thank also the Minister for going through in such detail all the points that have been raised and for agreeing to take some of them forward.