Nursing Quality and Compassion: The Future of Nursing Education
(12 years ago)
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Baroness Emerton
To ask Her Majesty’s Government what is their response to the recommendations of the report of the Commission established by the Royal College of Nursing Quality and Compassion: the future of nursing education.
Baroness Emerton
My Lords, I am grateful to have this opportunity to seek the Government’s response to the commission looking at quality with compassion in the future of nursing education. First, I pay tribute to the Royal College of Nursing for commissioning this independent commission at such a critical time in the life of the nursing profession and congratulate the noble Lord, Lord Willis, as chairman, and his team of commissioners. I also thank those who gave the evidence that resulted in such a clear, comprehensive report with 30 recommendations, all pointing to urgent action being required of the profession it if it is going to be equipped to deliver high-quality care with compassion. It is so desperately needed today and will be very much needed in the future with growing demographic trends and the increase in the elderly population with increasing healthcare needs and, at the same time, rising costs of treatment. Within the last week, we have had the example of an MP describing the terrible treatment her dying husband received from nurses. At the other end of the spectrum, the NHS Commissioning Board’s chief nursing officer, Jane Cummings, introduced her vision of nursing with a culture of care, compassion, courage, commitment and competence for the future.
I declare an interest, as recorded in the register, but in particular as someone who has been closely involved in developing the profession’s move into higher education, and the introduction of Project 2000, as a chair of the regulatory body, the UKCC. The Willis report clearly sets out the time taken since the Briggs report to reach the point we are at 41 years later, on the eve of a graduate programme being fully implemented in September 2013. When introduced, Project 2000 produced many adverse comments, as the report says, due to inadequate preparation of all concerned, in the universities and the providers. By not working together, we are experiencing adverse comments as to whether it is necessary for graduate training to give compassionate care. This report demonstrates that registered nurses, educated at degree level, are more than equipped to deliver high-quality compassionate care. It says:
“The public needs to know what it can expect of registered nurses educated at degree level. Stakeholders should scale up recruitment campaigns and other measures, including dialogue with the media, to promote better understanding of contemporary nursing and nursing education and dispel the myth that better educated nurses are less caring”.
Perhaps I and colleagues have not had the courage to stand up and be counted to ensure that the 41-year gap did not exist. The document goes on to identify the urgent need to supply an academic nursing workforce and guarantee its future quality. The NHS Commissioning Board, the CCGs, Health Education England and the local education boards hold the responsibility for commissioning the right number of students to fill the right number of places to deliver the patient care pathways for well-being, public health, hospital care, and community care through the health and social care services, not forgetting the voluntary services.
The mandate to the NHS from the Secretary of State does not include Health Education England. This is funded directly by the Secretary of State but there does not appear to be a mandate, only an outcome measurement. This is but one of the 30 recommendations. My question to the Minister is: how will the Government ensure that what is necessary will be provided to enable the responsible bodies to adopt the recommendations of the report? We cannot afford a further delay in implementing these recommendations, as has been the history of Project 2000 and graduate training. We should not forget that the initial graduate registration is not the end; there must be provision for professional development and postgraduate development, with investment in research to allow evidence-based practice and innovation.
I have listened to a number of recent briefings and the evidence to date is that the medical professions—I exclude the medical professionals present—have little or no recognition of other professions’ contributions to delivery of care, research or innovations. Again, this is probably the professions’ fault for not speaking loudly enough to be heard and included or providing the evidence to support their case. It may also be a reflection of the status of the nursing profession as viewed by other members of the health teams which is now beginning to erode the public’s view. The answer surely must rest in the hands of the members of the professions.
The serious current economic situation presents many challenges. However, the evidence to date is that the delivery of high-quality care is cost effective in reducing complications, early discharge and reduced mortality—in other words, high-quality care is not only cost effective but safe and acceptable to the public. The recommendation relating to workforce planning describes the need to address skill mix. It states that there is an urgent need to revisit the workforce policy and skill mix and suggests:
“A planned programme of regulation should begin with the mandatory registration of all staff who deliver patient care”.
This, of course, includes support workers. It is a false economy not to follow this recommendation. Although the Skills for Care and Skills for Health bodies are due to report in January, it is a requirement of the Act to have a voluntary register.
The report recommends that there should be mandatory training and registration for support workers. Can the noble Earl please give an assurance that this issue will be revisited? At Third Reading of the Health and Social Care Bill it was said that the costs would be too high. Is it possible for a more recent up-to-date analysis of the cost to be carried out, as the one quoted was taken from a 2009 cost of a housekeeping scheme which does not equate to the work of the healthcare support workers? There is a growing awareness within the profession and among the public that there are insufficient registered nurses in some parts of the health service, more especially on wards for the elderly. However, there is a higher ratio of registered support workers where most in-patients have multiple conditions and require the skills of registered nurses. Action is required to produce a more accurate and sensitive workforce plan.
Time does not allow me to explore more of the report and its recommendations, but it is essential to note that, despite all the recent bad press and the criticism of the nursing profession, there is evidence of excellent care being given by dedicated, caring and compassionate nurses and support workers. It is also encouraging that the students interviewed showed great enthusiasm for the profession they had chosen, and were determined to hold high the traditions. Where this is obvious, it reflects good leadership of the profession and an organisational culture that fosters high-quality, compassionate care within the framework of the NHS constitution. I hope that Her Majesty’s Government will take on board the recommendations so ably set out in the commission’s report.
Baroness Cumberlege
My Lords, this House is impoverished; we do not do ourselves justice. We have a paucity of Peers who are nurses. We have some splendid surgeons, physicians and Fellows of the Royal Society but, of course, we have the noble Baroness, Lady Emerton. Noble Lords will know that she is not only a very remarkable person but an extremely distinguished and highly respected nurse. However, it is unfair to expect her to carry the burden of the profession on her own. Therefore, my first question to my noble friend—I suspect that I know the answer—is: will he do all he can to influence those who make the decisions on membership of this House? Yet again, we are very indebted to the noble Baroness not only for securing this debate but for her knowledge, expertise—and courage, because she has left her sickbed to come here today. She exemplifies so much that we know is superb in nursing.
If the noble Baroness, Lady Emerton, is the heroine of the hour, the noble Lord, Lord Willis, is the hero. The noble Lord has written one of the best clear, concise, informative, authoritative and action-packed reports that I have read. It is a model for others to follow. I pay tribute also to the RCN and to Peter Carter, who commissioned this report and who exercised a self-denying ordinance not to interfere. It must have been tempting. The fear that we all have is that, like other excellent reports, this will sit on a shelf and there will be insufficient political will to implement it. Therefore, my second question to my noble friend is: what can he do to ensure that the report lives?
The noble Lord, Lord Willis, pulls no punches in destroying the irrational idea that kindness and intelligence are incompatible with an all-graduate nursing profession. He states that this is not simply desirable but essential—and I so agree. The concept that a nurse must be a professional among equals, a leader of teams and, in some cases, the head of a very large organisation, is not new. However, those in positions of great authority have been appointed against enormous odds.
A good education is never wasted. It brings with it not only knowledge but the confidence to hold one’s own in vigorous debate and argument. The debate is all about maintaining and improving compassionate care. That care has to be underpinned by professionalism, which depends on values, behaviours and relationships that can be inculcated at an early stage. They can be taught but in practice, with restricted budgets, they have to be defended, cherished and fought for. A well educated, confident nurse leader is essential to maintaining staff and improving the quality of care.
District nursing has always been the unloved cousin who is forgotten, does not receive presents and does not even qualify in this context for any specialist community training. I declare an interest as a fellow of the Queen’s Nursing Institute and of the Royal College of Nursing, and I am a patron of the Association for Nurse Prescribing; all my interests are in the Register of Lords’ Interests. The Queen’s Nursing Institute is one of the few champions of district nursing. Commenting on the Willis report, the QNI made the point that there is currently no requirement for district nurses to have any specialist community training. They do not even have to have experience of working outside of hospitals, despite recognition that care provided for patients in their own homes is unique; it is different. Universities are reducing, and in some cases, have ceased altogether to run courses.
I know that the commission was tasked with looking at pre-qualification training, but our policy is to keep people at home, which is where they want to be. That depends on ensuring that there are enough nurses with the right qualification and training. My third question to my noble friend is, would he consider a further report, akin to the Willis report, to look at post-registration training.
The number of community nurses, particularly district nurses, is falling. In 2009, we saw, for the first time, the number of qualified district nurses in England fall to below 10,000, which represents a 23% reduction in the past 10 years. The most recent figures available, for the year up to September 2011, shows another fall of almost 10%. Furthermore, the community nursing workforce tends to be older, and some figures claim as much as 59% of current community nurses plan to retire in the next decade. I believe that this is a crisis in the making, and it will thwart the Government’s current plans to see fewer patients admitted to hospital. However, the Government are to be congratulated on their recent focus on the recruitment of health visitors. They have a clear plan, complete with measurable targets; they have provided a useful, recent example of a concentrated recruitment effort. My fourth question to my noble friend is, therefore: will he explore a similar commitment to district nursing?
I want to address the subject of healthcare assistants, but I appreciate that I am running out of time, and I have not got time to do that. However, I must say to the noble Baroness—and I regret having to say this—that I am not yet truly convinced that registration is the answer for healthcare assistants. Ultimately the employers must be accountable for the training, competence, supervision and performance of their own staff.
With the report of my noble friend Lord Willis, and the powerful strategy launched last week, referred to by the noble Baroness, Lady Emerton, we can see a real change for the better, a brighter future for nursing and a comprehensive return to compassionate patient care, which is, after all, what we all want.
Lord MacKenzie of Culkein
My Lords, I am grateful to the noble Baroness, Lady Emerton, for putting down this question to the Government today.
It is apposite that we should have an opportunity to discuss the matter of care and compassion in another week when issues have again been raised about the quality of care, not least by the awful story told by Ann Clwyd MP at Prime Minister’s Questions last week. There is a very similar on the comment page of the Nursing Times of 4 December, written by a senior lecturer in the Faculty of Health and Wellbeing at the University of Cumbria. It has not been a good week for the nursing profession, not least with the release of the final report on Winterbourne View yesterday.
As a nurse, and as someone who has worked for nurses and nursing for most of my working life, I feel deeply saddened by the adverse publicity that my profession is now getting. This stuff will run and run; it will take a lot of time and hard work to mend the damage that has been done.
The question before us today is about the report of the Willis commission. The noble Lord, Lord Willis of Knaresborough, deserves our thanks for undertaking this very important piece of work. I would disagree with little, if anything, in the report. In the introduction to his report the noble Lord, Lord Willis, said that,
“there has been insufficient political or professional will”,
to implement past recommendations. He expresses the hope that that will not be the fate of his report. I sincerely share that hope. As has already been asked of the Minister, I hope that he will tell us that this time we will go down the right path.
The nursing world has in many respects changed out of recognition since the days long ago when I commenced my training. However, some things have not changed. It is not new that there are brilliant nurses, good nurses, some who are less good and some who are not suited to the profession. In my student days, when most started training at the age of 18, many of these were eased out during training.
Neither is the debate new about whether nurses are the finished article on registration. I can remember nurses who thought they had arrived and done it all on the day they completed their training. I much preferred the view that one really started to learn only after one qualified and took some measure of responsibility and accountability.
The issue of fitness to practise on registration is often discussed, but it must depend on the appropriateness and quality of education and the quality of teaching on placements followed, after graduation, by good preceptorship and clinical supervision. I have a relative who is a lecturer in a school of nursing and midwifery in a university. She tells me that they are not allowed to go into hospitals and wards to see what their students are doing, although I understand that teachers in some other universities can; indeed, I know they can because one used to appear at my bedside in uniform, complete with Barts badge to supervise what her students were doing and procedures. However, I gather that some not being allowed to supervise any work is something to do with universities and vicarious liability. That underlines my view that we need a return to clinical teaching. Pressures on ward sisters and mentors are such that there is a gap here. It is not necessarily the case, as some academics argue, that clinical teaching disrupts the natural process and flow of care.
I will touch briefly on workforce planning and commissioning. The Willis report underlines the difficulty in getting good statistics and the risks of workforce planning being left to local employers. I endorse the commission’s view that there must be a well developed UK oversight. The future cannot be left to short-termism and localism.
My union, the Confederation of Health Service Employees, supported the Project 2000 proposals to move away from apprentice-type training and into the higher and further education sector. We also supported the ending of enrolled-nurse training, as it then was; I still have the scars on my back from trying to further that argument with many enrolled nurses, including my own daughter. What we did not support was that there should be no other form of regulated training for staff that would in the future carry out much hands-on care—what I still prefer to call nursing care.
I spent many months travelling the country addressing meetings on Project 2000 and the ending of enrolled-nurse training, and advocating COHSE’s policy of an entirely new second level that did not have the problem of confusion of roles between the first and second levels as there then was. We wanted a new second-level support nurse trained to an agreed standard of about a year or so. Apart from the support of a couple of regional nursing officers, we ploughed a lone furrow. There was no real support from the leadership of the profession at that time.
The quite proper drive to enhance the status of the nursing profession has left us now with a plethora of support workers of varying training, or little or none, together with a multitude of job titles, delivering a great deal of nursing care. As the commission of the noble Lord, Lord Willis, puts it, that care is delivered with greater or lesser supervision. We need to do something now about the training of support workers. In reality, with the demographic pressures and financial pressures that there are going to be, there will be fewer degree-level nurses and more support workers. That much care is not going to be delivered by nurses themselves.
It is not part of my purpose to rubbish support workers. Many, in my experience, are excellent, but they need to be trained to an agreed standard, and they need to be regulated and registered. Some progress is being made—I have no doubt that the Minister will reinforce that—but it is not enough. I know that he has heard me on this subject before, but it is wrong and unconscionable that nurses have to accept responsibility for staff whose abilities and competencies cannot be relied upon.
There are a number of issues facing us. Some of these are cultural, although I personally find it difficult when I hear of curtains not being drawn around a bed. The noble Baroness, Lady Emerton, will well remember that we were taught to do no procedure without having first pulled the curtains around the bed and telling the patient what we were going to do. Nobody ever did anything without that ringing in their ears. It is not difficult to do, and not difficult to teach.
My final plea is that the ward sister should be supernumerary and accountable, and that senior management should be accountable because it is not always the staff at the sharp end who should carry the can. We need to get the education, the training and the skill mix right, and must not leave everything to localism. There has to be some national responsibility and accountability. I hope that nurse leaders will continue, as I know that they will, to fight to restore the image of our profession. If not, there will be more inquiries, more scandals and, perhaps, a royal commission. I hope that we do not get that.
Lord Willis of Knaresborough
My Lords, I congratulate the noble Baroness, Lady Emerton, on securing this debate and I echo the comments made by the noble Baroness, Lady Cumberlege, about her efforts in the House. The fact that only four out of 788 Peers have a nursing background is a sad reflection on how important this profession is and how little it is regarded in terms of our debates and our work. I also thank the noble Baroness, Lady Cumberlege, for her very kind comments, particularly referring to district nurses—my mother was a district nurse and I remember only too well sniffing her bag.
The appalling events at Winterbourne View, which we discussed last night, and the disturbing revelations by Ann Clwyd about her husband are graphic reminders that care by nurses, or indeed other healthcare professionals, is not always what it should be. That has to be a starting point, rather than believing that everything in the garden is absolutely rosy.
This short debate does not allow us to look at the complex reasons why sometimes care breaks down but, no matter how difficult it is, I share the view of the general secretary of the RCN that poor practice has to be exposed. It has to be understood why it has happened, it has to be rectified and there should never be an excuse to patients or their carers about a lack of compassion.
I was privileged to be asked by the RCN to lead the independent review, which was about pre-registration nursing in the wake of changes to the Nursing and Midwifery Council standards and indeed to the growing media criticism that nurses were “too posh to wash” and “too clever to care”. Those descriptions were absolutely appalling to apply to any professional. Such comments were predicated on the assumption that the move to an all-graduate education programme for nurses would result in the recruitment of less caring and less compassionate students.
Today the vast majority of nurses are not graduates. If poor care is occurring today, it is not because we have graduates. In fact it will not be until 2013 in England that all entrants as registered nurses will be graduates. Making the bland assumption that by expecting higher educational attainment from nurses means you will get less care and compassion is absolute nonsense.
More than 100 organisations gave evidence to us, from every strand of opinion. We interviewed 29 witnesses, from the RCN to Health Education England; from charities to the NMC; from the Council of Deans to patient groups. I went over to Belfast and to Dundee, Cardiff, Oxford and Huddersfield to interview patients and to look at what was happening. Not one produced a shred of evidence to support the idea that raising academic standards would lower care and compassion, so we need to knock that on the head. We want the brightest and best of our young people, and indeed our mature entrants, to come into the profession. We want them to include care and compassion as part of those qualities.
Central to our report was the belief that patients must be at the centre of the education of tomorrow’s nurses. Universities must also do far more to ensure that patients and their representatives are central to recruitment and to programmes. If nursing is not about patients, quite frankly it is not about anything. We too often get tied into structures and to organisation rather than the root causes of what we are trying to do. I make a plea, too, for research to be placed right at the heart of training. I met students who saw the research component as an addition. You tick that box to become a graduate. I argued that that was not what graduateness is about. Graduateness is about developing critical thinking. It is about leadership. It is about challenge and if you are not building research right into the heart of it for nurses to ask: “Why am I doing this? Is there a better way of doing it? Can I be involved in a project to look at doing things better?”, then I think we are missing a trick.
I will finish, because of time, with the issue of healthcare support workers. The vast majority of patients I met did not understand the difference between a nurse and a healthcare support worker. Having a chart at the front of the hospital, showing people wearing fancy uniforms of different colours, really does not tick the box; when you are brought into an emergency ward, the last thing you want to do is say, “Stop, can I just have a look at the chart to see who everybody is?”. It is an absolute nonsense. I share the view of the noble Lord, Lord MacKenzie, that the vast majority of these people are hard-working, diligent and want to do a very good job. However, there is not a single care home in the United Kingdom that does not rely virtually entirely on this brilliant and dedicated workforce, which often performs tasks, including dispensing medicines, without any training or background and without there being any way of registering or regulating its members.
How can it be—I say this to the noble Earl, who I know is the most caring of Ministers—that the most vulnerable patients in the United Kingdom, often in their own homes and at the latter stages of life, are cared for by an underqualified and unregulated workforce? How can we allow that? We recognised, as a commission, how difficult it will be to move to a regulated and fully trained workforce. It cannot be done overnight, and to pretend that it can is fanciful. However, we should be making a start, which is what the commission recommended.
The idea of a voluntary register is perfectly okay for good providers—but they do not need a voluntary register, because they do it already. A voluntary register would not have made the slightest difference to Winterbourne View. I make a plea to the Minister that I would like to see all 29 of our recommendations referred to by the Minister in a proper report back. Ultimately, I am enormously grateful for having this opportunity to place the report before this Committee.
Lord Kakkar
My Lords, I join in thanking the noble Baroness, Lady Emerton, for securing this important debate and in congratulating the noble Lord, Lord Willis of Knaresborough, on his excellent report. I declare my own interests as professor of surgery at University College, a practising surgeon at University College London Hospitals NHS Foundation Trust and a member-elect of the General Medical Council.
The report that we are considering today is both reassuring and worrying. It is reassuring because it speaks with great optimism about the talented, dedicated and committed people who are still attracted to the vitally important profession of nursing. However, it is worrying because in describing the background that resulted in the necessity for this report, it highlights a worrying deterioration of organisational culture and values that have allowed patients to be characterised as statistics and consumers rather than as vulnerable and anxious human beings coming into our healthcare system and look at healthcare in terms of episodes of delivery of care rather than the delivery of healthcare in terms of compassion and dignity.
This report, rightly, identifies that providing an undergraduate basis for initial training in nursing is not attended by any inability either to develop the clinical skills and standards necessary for this important profession or to ensure that nurses qualify with the appropriate level of commitment and compassion that is vital to delivery of this important profession. The evidence available in the published literature from the United States and Canada shows that for every 10% increase in the number of nurses on the workforce who have reached a bachelor’s degree standard there is a 5% reduction in overall institutional patient mortality. If you look, for instance, at outcomes in surgical practice, the larger the proportion of highly educated nurses, the lower the perioperative mortality. In Canada, there is evidence looking not at surgical patients but acutely ill medical patients: those with heart attacks, strokes and acute respiratory problems. A similar pattern is demonstrated—the greater the level of nurse education, the greater the overall improvement in outcomes, with lower mortality. If one looks specifically, again in Canada, at discharges from acute medical wards, one sees that for every 10% increase in the number of nurses on staff having achieved a baccalaureate or higher level of education, so there is an improvement in survival, with nine fewer deaths per 1,000 patients discharged.
There are four issues in this important report on which I would like to seek further guidance from the Minister. First, preceptorships are very much like the original one year of house jobs prior to full registration with the General Medical Council for doctors, now reflected in the foundation year 1. It has been suggested that these preceptorships should potentially be extended from the original recommendation of four months. However, as is the case with newly qualified doctors, should it be necessary for the dean of the nursing school to have to sign off the graduated candidate at the end of this period of preceptorship before they can achieve full registration with the Nursing and Midwifery Council? This would ensure that those being delivered from the undergraduate programme could demonstrate that they have all the skills necessary to continue to full registration, having had to perform in a potentially stressful clinical environment for a period of time after immediate qualification.
The second area is one of graduate training to ensure that the most able and talented leaders in nursing can rapidly move through their period of post-qualification training and development to take up leadership roles such as those at ward sister level, while still being in a position to deliver front-line clinical care throughout that process.
At University College London Partners, where I chair the quality outputs, we have developed a programme called Excel which does exactly that. It takes the most talented nurses across the organisations within the partnership through a programme of development that will shorten the time from an average of seven years to just four years, in which they can take on senior nursing positions within our organisations, while continuing to maintain a strong clinical focus. Will Her Majesty’s Government support similar programmes across other academic health science networks when they are established, to ensure that we fast-track nurse leaders, helping them to continue their professional development, while maintaining a focus on the compassion and kindness which is ultimately the fundamental basis for all healthcare delivery?
In this debate we have already considered mandatory registration for healthcare support workers. This is a vitally important requirement. As we start to look at teams delivering care, with teams of different skill mixes, it is vital that all members of that team have to perform to a similar level and are able to command the same confidence from members of the public coming into hospital. It does not seem right that only some members of the team are subjected to statutory registration and not others. Have Her Majesty’s Government changed their mind on this? Are they now in a better position to recommend and provide a statutory basis for such registration?
Finally, on revalidation for nurses, as we move to a graduated profession it will be vitally important that, as we see with revalidation for doctors, nurses are also subjected to revalidation to ensure that the skills that they have developed early in their career are maintained throughout it. At the moment, registration requirements are reflected in 450 hours of practice in a specialist area over three years, and 35 hours of continuing professional development on an annual basis. But revalidation means much more than this. Will Her Majesty’s Government provide a statutory underpinning for revalidation of the nursing profession?
Lord Patel
My Lords, I realise that my time has been cut down; I was running the risk that I would be completely eliminated in a minute. However, I will try to cope with the three minutes that I now have.
First, I thank the noble Baroness for initiating this debate. I am sorry to hear that she is feeling unwell, but if she will kindly tell me what might be the best treatment, I will write a prescription. This is why I have always been used to taking advice from nurses first.
It is interesting that in this debate we have two nurses, two doctors, three former Health Ministers and a former teacher, who wrote the report on nursing education; and no doubt the current Minister will be the one to reply to it.
I had intended to concentrate on three issues: workforce planning, which the Willis report mentions; the education of nurses; and the registration of support workers. I will come to the last first.
I support what the noble Baroness, Lady Emerton, and the noble Lords, Lord Willis, and Lord MacKenzie, had to say. We have had this opportunity to discuss the large number of nursing support workers who are currently unemployed, and their training and registration. We will keep coming back to this until it is resolved. It is unacceptable that the Government still seem to think that employers should be responsible for whether these workers should be registered or not, and whether or not they should have training.
It is quite clear that the training of health workers who provide front-line healthcare should be mandatory. There should be a curriculum and an assessment, and they should then be registered. I understand that it is not possible to have a compulsory register straight away. However, we need to have a road map that will enable us to leave voluntary registration and move to proper registration.
I have no doubt that the Minister will not agree, but I am sure that we will keep coming back to this, and I look forward to a day when one of the political parties, when in government, will introduce registration. I hope that that will be the current Government.
I refer to two reports, both from the Royal College of Nursing. One, the Willis report, was commissioned by it, and the other was the Royal College of Nursing report, Overstretched. Under-resourced. The UK Nursing Labour Market Review 2012, which was published in October. Both of them highlighted the issue of what will happen to the workforce planning of nurses.
Experience in the 1990s showed that cutting student numbers led to a year on year reduction of new entrants, from 18,980 in 1990-91, to 12,000 in 1997-98. This contributed to an acknowledged nursing shortage later in the decade. The report highlights that there is a risk of repeating this funding and planning, for in 2011-12 there were approximately 22,640 places across the UK for nurse training, compared to 24,800 in 2010-11. Next year, there will be another 1,260 fewer places, with a total of around 23,000.
Workforce planning will be left at the local level, first of all with the local education and training boards, which will work with the commissioners to define how many training places there should be. Health Education England will then be charged with funding the numbers, and the national Commissioning Board will be responsible for providing oversight. The whole thing, therefore, will be left, with all due respect, to the managers, without any reference to the professionals who provide direct patient care.
In the report of the noble Lord, Lord Willis, the managers, NHS employers, felt that they,
“have confidence that through a co-operative and collaborative approach between service and education providers, the future workforce will not only continue to deliver quality care but will also be equipped to develop and deliver new and dynamic services for patients”.
I come back to my first point about support workers. The result of this will be more support workers, because costs will be cut, and there will be fewer graduate nurses. I declare an interest as the chancellor of the University of Dundee, where I have graduated several hundred nurses, the last occasion being on 14 November. I was also pleased to award several PhDs, so nursing is developing as an academic profession as well. I am therefore totally signed up to nurse graduates. I therefore plead with the Minister to look again at the training and registration of support workers.
Lord Hunt of Kings Heath
My Lords, I, too, must declare a number of health interests that are on the register—principally as chair of the Heart of England NHS Foundation Trust. I also thank the noble Baroness, Lady Emerton, for initiating this debate. In fact, only two weeks ago she presented badges to some of our nurses who had passed the trust’s intensive internal examinations. I am particularly indebted to her for doing so. I am also glad that my noble friend Lord MacKenzie, the other nurse speaking in this debate, spoke so eloquently and provided a background to some of the issues that laid the foundation for some of the concerns about the quality of nurse education.
In discussing the concerns, I hope that we acknowledge the tremendous strides the profession has made in the past 20 years. Nurses have taken on a lot of specialist skills and are looking after a much higher proportion of frail elderly patients with comorbidities. They have taken on other responsibilities as well. The noble Baroness, Lady Cumberlege, was very much responsible for that. I think of the work that she has done as regards childbirth and nurse prescribing. However, as the noble Lord, Lord Kakkar, suggested, we have this irony that at the same time as we have seen the huge potential of nurses there is concern about neglect of basic standards of care. We have all heard Ann Clwyd MP’s moving and distressing description of her husband’s last days and what he described as the indifference of some nurses.
The noble Baroness, Lady Emerton, referred to Project 2000, at which many point the finger of blame. However, I am glad that in his excellent report the noble Lord, Lord Willis, endorsed the ambition of a graduate nursing profession. I am sure that that is important, but I hope that the Minister will reflect on problems regarding the education of nurses within our universities. Clearly something is wrong. I believe that the monitoring of the curriculum has been left in the main to HR people in the health service and to the universities themselves, and that that has often led to major problems. HR people do not know about standards of nursing care—they are not in a good position to make decisions about these commissions—and universities are concerned with academic issues. They are not concerned with practical nursing standards on the ward. I believe that the answer—I am biased—is to allow the NHS to have much more involvement in the training and selection of nurses in the future. I am not suggesting that we go back to the old hospital nurse training schools, but NHS trusts need to be much more involved in future. My own trust is in discussions with the university hospital in Birmingham and the University of Birmingham about a tripartite approach to nurse training. That must be the way forward. I hope that the new regional structures will not get in the way of that.
My understanding is that the Nursing and Midwifery Council intends to deal with revalidation in about 2015, after clearing up the problems that it has. I very much welcome its approach. I also welcome the current leadership of the NMC, who show every sign of getting to grips with the many problems that they have inherited. I hope that the noble Earl agrees with the comments made on research. It is so important that we give more emphasis to nursing research.
My noble friend Lord MacKenzie spoke about the importance of supernumerary status. I agree, but I say to him that there is an issue of resources—I need to come back to that—and of being able to afford it. The noble Lord, Lord Patel, spoke about workforce planning. I urge the Government not to not leave it to local people to decide the number of commissions. We know that that will be a failure. I remember appearing before the Health Select Committee about five years ago to explain why education commissions had been reduced. I endured two not very happy hours doing so. I assure the noble Earl that his ministerial team will have the same problem. I gather that doctor commissions are also being reduced. This will prove to be a major mistake which the NHS will pay for one way or another in about five to 10 years’ time.
I will not repeat what other noble Lords have said about healthcare assistant regulation. The Government have been wholly unconvincing on this as, frankly, has the central health regulatory authority. We have to have the regulation of healthcare assistants; patient safety demands it. There is a clear consensus, and the only people opposed to it are the central regulator, which for some bizarre reason seems to cling on to this idea that you can do it through voluntary accreditation, and the Government. The intellectual argument against regulation seems very weak indeed.
Finally, before we put all responsibility for lapses in care in the hands of nurse education and the lack of regulation of support workers and of nurses themselves, we cannot ignore the huge nursing challenge posed by the increasing number of frail elderly people in our hospitals who are suffering from multiple chronic conditions. It is also grossly unfair not to recognise the financial pressure on the NHS at the moment. Nurse to patient ratios are being squeezed, and the reduction of the number of nurses in employment is an indicator of that. The Government must own up to the fact that they themselves are creating some of the pressures that are making it harder for nurses to do the job they want to do. I believe that we will come back constantly to these issues until we are able to resolve nurse education training, sort out the regulation of healthcare assistants and create the conditions in which nursing care can thrive.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the noble Baroness, Lady Emerton, has been a tireless champion of the values and standards that underpin good nursing. This debate, on which I congratulate her, is therefore no surprise. Listening to her excellent speech reminds us once again of her long-standing expertise and wisdom in the field of nurse education and the regulation of the nursing profession.
My noble friend Lord Willis published his very comprehensive and helpful report into the future of nurse education in November. The report was the result of deliberations by his independent commission, which was established by the Royal College of Nursing under his consummate chairmanship. On publication, the report was handed to the chair of the RCN for her consideration. It was not a report to the Government and we will therefore not be formally responding to it. However, I recognise that its 29 wide-ranging recommendations are important and, as this debate has shown, need to be given due weight and consideration by leaders of the nursing profession.
As part of government changes, a new Secretary of State for Health was appointed this year. He has clearly stated that he has four priorities for his term in office: to improve the general quality of care, including nursing care; to rise to the challenge of caring for people with dementia; to improve the management of long-term conditions; and to reduce avoidable deaths from the major diseases. These priorities, importantly, impact on nursing care and nurse education and come as national nursing leaders have also changed significantly during the year. As part of the Health and Social Care Act, which passed through your Lordships’ House earlier this year, the NHS Commissioning Board was established, alongside the separate creation of Health Education England, both of which have prominent nurse leaders.
The noble Baroness, Lady Emerton, asked for some assurance that these bodies will take full account of the Willis report. Jane Cummings has been appointed chief nursing officer for England on the NHS Commissioning Board and Lisa Bayliss-Pratt is director of nursing for Health Education England. Both have significant leadership roles in the education and training of nurses, and I can tell the noble Baroness that they are looking at the Willis report in detail. Health Education England takes over the Secretary of State’s duties for ensuring an education and training system fit for purpose, and the chief nursing officer for England and the director of nursing for Health Education England will collaborate very closely in that regard.
My noble friend Lady Cumberlege asked what would make the report really live. It has a high degree of resonance across the profession already, with nurse leaders in the vanguard who will help ensure that it does not gather dust. Earlier this month, Compassion in Practice, a vision and strategy for nurses, midwives and care staff in the NHS, public health and social care, was published jointly by the chief nursing officer and the director of nursing in the Department of Health and lead nurse for Public Health England, Viv Bennett. Compassion in Practice articulates the values and behaviours expected of nurses, midwives and care staff. These values and behaviours are expressed as the “six Cs” of care, compassion, competence, communication, courage and commitment, each of which resonates with findings and recommendations of the Willis report.
This is not a vision without action. One area for specific action will be to ensure that the NHS, public health and social care services have the right staff with the right skills in the right place. This means that staff will be recruited for their values and behaviours as well as their capability to be lifelong learners. This point was made by a number of noble Lords. Importantly, the Willis report recognises how demanding and rewarding the practice of nursing is. It states very clearly that it found no evidence that revealed any major shortcomings in nursing education that could be held directly responsible for poor practice or the perceived decline in standards of care.
My noble friend and his commission are unequivocally supportive of degree-level registration for new nurses. This commitment by the Nursing and Midwifery Council will be fully implemented by September 2013. I am aware that the noble Baroness, Lady Emerton, too, is fully supportive of that. When it comes to achieving this change to nurse education, my noble friend Lord Willis rightly emphasised that educating nurses is a partnership between the NHS and universities. The noble Lord, Lord Hunt, was right to emphasise that. Student nurses cannot qualify and register if they have not satisfied both the university and, in practice settings, their NHS mentors, who formally assess them for their practical skills and knowledge as well as for their values, behaviours and ability to give care with compassion.
The compulsory state regulation of currently unregulated health and social care support workers in England is a topic that has arisen throughout the debate. It is a live issue in the nursing profession. We recognise the need to drive up standards among health and social care support workers, and have commissioned Skills for Health and Skills for Care to develop a code of conduct and national minimum training standards by January 2013. In addition, the Professional Standards Authority will have powers to accredit voluntary registers from this month. The Skills for Health and Skills for Care work will, for the first time, set clear national expectations about standards for these workers.
Health and social care assistants already work in environments that are subject to regulation by the Care Quality Commission. The Independent Safeguarding Authority can take action to bar them from working in regulated activity. Further, the work they do should be delegated to them and managed by staff—usually nurses—who are themselves subject to professional regulation and should not be asked to undertake a task for which they are not trained. The care given by health and social care support workers is at the heart of NHS-funded services. We plan to keep this under review in the light of the findings and recommendations in particular of the Francis inquiry, which is due to be published in the new year, to ensure that the system and process remain fit for purpose. I will repeat what I said yesterday at the Dispatch Box. The Government’s mind is open but we need to ensure that there is a good, evidence-based case before proceeding with mandatory regulation.
The noble Baroness, Lady Emerton, asked whether there had been a more recent cost analysis than the 2009 data of registering healthcare support workers. The answer is, not to my knowledge. Clearly, the cost of regulating 1.8 million health and social care support workers would be significant, but the basis of our decision not to regulate was not cost. Those who advocate regulation of support workers sometimes speak as if regulation were a panacea. I do not believe it is in any way a substitute for performance management. The duties of a support worker are always delegated from a responsible registrant, usually a nurse, as I have mentioned, and that fact could not, and should not, change.
If the concern is that we are somehow exposing patients to unacceptable risk by not regulating, then again, I do not think the assumption underlying that suggestion—that regulation would be the answer—is valid. It implies that support workers are inherently dangerous, which I do not accept at all. If a support worker were to be seen as a danger then, as I have mentioned, the Independent Safeguarding Authority has a vetting and barring scheme which can prevent unsuitable support workers being employed.
My noble friend Lord Willis asked about research as part of a nursing degree. I absolutely agree with what he said in that regard. It is already, in fact. Nurses, as undergraduate nurses, will be able to critically appraise research. Some will wish to become researchers and there are nationally funded clinical academic training schemes to support this.
A number of noble Lords, including the noble Lords, Lord Hunt and Lord MacKenzie, spoke about nurse education. Planning the number of nurses and the size and shape of the workforce has to be based on the needs of the people in our care. Services must be properly designed around the care and treatment that people need and these decisions could result in the need for nursing numbers to change, and very often they do.
At present, SHAs work with local employers to determine nurse training commissions. From April next year, Health Education England assumes national leadership for a new system of planning and developing the entire healthcare and public health workforce. HEE will ensure that the shape and skills of the future health and public health workforce evolve to sustain high-quality health outcomes in the face of demographic and technological change.
From 2013 all nurse education programmes will need to meet the new education standards set by the NMC and we support the NMC’s decision, as I have mentioned. It is the right direction of travel if we are to make all nursing degree level and if we are to fulfil our ambition to provide high-quality care for all.
Time is against me, so I will endeavour to cover just a few more questions but I will write to noble Lords with answers to other points.
The noble Lord, Lord Kakkar, asked me about preceptorship and I listened to his remarks with interest. Preceptorship is a development framework for newly qualified practitioners which, as he outlined, aims to ensure the smooth transition from student to qualified, accountable practitioner through a programme of bespoke support. It is predominantly administered through employment. We plan to develop the preceptorship framework further during 2012-13 within a clinical leadership framework. Work has commenced on that project and should be delivered by next April.
The noble Lord asked about deans of nursing schools signing off candidates after a period of preceptorship. That is an interesting idea which I do not believe has been fully discussed across the profession. I will ask officials to test the proposal with the Nursing and Midwifery Council and the Council of Deans of Health.
Will we support schemes for the fast-tracking of nurse leaders? That idea is most definitely supported and we have committed to £40 million in 2013-15 for leadership development that will assist aspiring and talented nurse leaders. Unfortunately, time prevents me from expanding on that, which I would like to have done.
The noble Lord, Lord Hunt, asked about monitoring standards of care by students. It is right that nurse education is a partnership between the NHS and universities, as I have mentioned, and it is true that the NHS must be more involved with the selection of students. Health Education England will work on that.
I think my time is now up. I thank noble Lords for a very rich and rewarding debate which, as I have mentioned, I will follow up in writing to all noble Lords who have spoken.