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Lord Hunt of Kings Heath
Lord Hunt of Kings Heath
My Lords, it is a great pleasure to open the Committee stage debates on the Care Bill. Schedule 5 relates to the establishment of Health Education England as a non-departmental public body. Schedule 5 is concerned with the membership of Health Education England and other matters to do with its establishment. As this is the start of Committee stage, I declare an interest as chair of an NHS foundation trust, and as a consultant and trainer with Cumberlege Connections.
The education and training of staff in the National Health Service is of course a critical responsibility, on which patients depend for good outcomes of care. The UK has traditionally enjoyed a very high reputation for the quality of our training and educational institutions and for the standing of the professional staff who come into the National Health Service. However, we should also acknowledge that there are a number of challenges facing the UK in ensuring that we continue to produce the right kind of people, in the right specialties and in the right numbers, taking into account the long-term challenges we face, not least that of an ageing population.
We received lots of briefings for this part of the Bill, for which I am most grateful. I was particularly struck by the briefing I received from the Royal College of Physicians, which points to trends in medical education and training. On demography, it points out that by 2033 there will be 3.2 million people above the age of 85, with the prevalence of dementia expected to double. On social trends, people have more choice and higher expectations. On efficiency, the economy of course will shape services substantially and we know that, in the short term at least, the NHS faces unprecedented austerity.
While the Royal College of Physicians believes that many elements of the current training structure are excellent, there is a need for change too. Many more physicians must train in internal medicine to meet the new needs of patients across hospitals and community services. There is an emerging view that too many consultants specialise too soon and that there is a need to focus more on general physician consultants if we are to meet some of the problems that hospitals are facing. A&E is a symptom of the need for hospitals, in particular, to change the way they are often organised in order to recognise that their key client group are frail, older people who probably need the attention of generalist physicians as much as speciality doctors. The RCP points out that the doctor-patient relationship is evolving and that this needs to be reflected during training. It says that there should be more flexibility for time out of training and career progression between different grades which meets the changing needs of the health service.
Every royal college and many trade unions and patient groups have made similar comments about the need to look at the training and education of our professionals. We know that there are formidable challenges with regard to nurse education. The Francis inquiry identified a number of these. There is a real worry that newly-qualified nurses are not well prepared to take on full nursing responsibilities. The excellent independent report of the noble Lord, Lord Willis, commissioned by the RCN, contains some very important messages for us in our debates. There is a debate among the public and in Parliament about whether the caring aspect of nursing has sometimes been neglected. There is also the issue of whether healthcare support workers lack mandatory training and registration. I have no doubt that we will also debate those matters.
The connection between this and Schedule 5 is that Health Education England will be faced with many interesting and difficult issues. I can say to the noble Earl that we support the establishment of HEE in statute and I am very glad that Sir Keith Pearson has been appointed as chair of that organisation. The noble Earl will know that he was previously the distinguished chair of the NHS Confederation and an NHS trust. He brings to the job a wealth of experience.
The amendments in this group are designed to enhance the ability of Health Education England to understand the pressures that the service is under in relation to staffing and to ensure that our education and training is flexible to the rapidly changing face of health and social care. There are three amendments concerning the membership of Health Education England, as set out in paragraph 2(1) of Schedule 5, which states:
“The members of HEE must include persons who have clinical expertise of a description specified in regulations”.
Amendment 1 seeks to delete that but I hasten to add that it is a probing amendment. I have no problem at all with people of clinical expertise being on the board—far from it. However, I seek assurance from the noble Earl that one of the members appointed will be a registered nurse. This relates also to Amendment 3.
I need hardly speak to the House of the importance of nursing issues to the workforce and to the work of Health Education England. I remind the noble Earl of recommendation 204 of the Francis report into Mid Staffs. It states that all NHS bodies,
“should be required to have at least one executive director who is a registered nurse, and should be encouraged to consider recruiting nurses as non-executive directors”.
I hope that the noble Earl will be able to respond positively. The nursing workforce is so important to the quality of care that it is crucial that Health Education England has nurses around the board table both on the executive and non-executive sides. Every time there is a restructuring of NHS boards, often there will be people who try to exclude nurses from those boards. They are mistaken. I do not think that boards in the NHS can do without nurses around the top table.
My noble friend Lord Turnberg will of course speak to his own amendment but I support its thrust, which is to appoint one or more members with expertise in research and one or more with expertise in medical education and training.
I also hope that recognition will be given to the needs of those staff who are not professionally registered. My Amendment 4 refers to that point. How are the needs of healthcare assistants going to be met if there are not people around HEE who understand the constraints and pressures under which they work?
Managers in the health service, many of whom are not qualified in the traditional sense of being professionally registered, have a crucial role to play. I had hoped that Health Education England would be concerned about the identification and development of those managers. I remind the noble Earl that there is a big problem in recruiting chief executives to NHS bodies, perhaps because their length of stay is almost as bad as that of football managers. That tells it own tale about the job. I hope that Health Education England will consider that it has some responsibility to look at how the managerial cadre can be developed and trained, and how they can be given some security in their jobs and reassurance about what will happen to them if they need to move on from one organisation to another.
The Deputy Chairman of Committees (Viscount Ullswater)
My Lords, I must advise your Lordships that if this amendment is agreed, I will not be able to call Amendments 2 and 3 because of pre-emption.
Lord Turnberg
My Lords, I will speak to Amendment 2. Before I do so, I should explain that I have heard from the noble Lord, Lord Patel, who cannot be in this place this evening because of illness in the family. I strongly support the amendments of my noble friend Lord Hunt, in particular the idea of a nurse on the boards; I also very strongly support his ideas on trying to attract good managers to stay in the service for as long as possible.
Amendment 2 is the first of several amendments that I have tabled emphasising the need for Health Education England and the local education and training boards to pay particular attention to the maintenance of standards and quality in education and training. I express my interests here as someone who has spent many years trying to raise standards of medical education in my previous jobs as dean of a medical school, the president of the Royal College of Physicians and, perhaps of equal significance, as president of the Medical Protection Society, where I was brought face to face with what happens when standards fail or are allowed to slip.
This amendment specifically concerns the membership of Health Education England and the need for it to include at least one person with expertise in research and another in education and training. I will save my remarks on research until we debate later amendments, but so far as education and training are concerned, my fear is that in the drive to meet workforce requirements and staffing numbers we will lose out on standards and quality. This amendment simply makes more explicit the need for input on the board of someone who has particular expertise about education and training, and the maintenance of standards.
I will make another point now to save making it later. I believe that there is a conflict, not easy to resolve, between the desire to provide sufficient numbers of trained staff locally—as determined, quite rightly, by local providers—and the need to maintain national standards. For example, in medicine it is vital that a cardiologist, orthopaedic surgeon, general physician or trained nurse is trained to a national standard that is recognised everywhere. It is not acceptable for a local provider to decide what training should consist of, but they want someone whom they can rely on. It is vital that there are national standards and hence there is a need for someone at the Health Education England level who has the expertise to look at how those standards can be set.
So far as national workforce planning is concerned, I have lived through innumerable efforts at medical workforce planning and found them to be fraught with difficulty, largely because it takes so long to train doctors: five or six years as undergraduates, then another five or 10 years of specialist or general training. Predicting need for different types of doctors 10 or 15 years downstream is far from straightforward. The noble Earl kindly sent around a document on a mandate from the Government to Health Education England. However, I fear that the section entitled “Excellent Education”, with its emphasis on training multipotential individuals working in teams across all health sectors—important though that is—de-emphasises the need for specialists. That prospect fills me with apprehension—that five years downstream we will have a health service lacking essential parts. I fear that the right balance between the need for general across-sector care and specialist care may be tipping too far in these particular aspirations. In any event, for the moment, I will press for the placing of relevant education expertise on the board of HEE, as suggested in this amendment.
Lord Willis of Knaresborough
My Lords, in the Second Reading debate on the Health and Social Care Bill, now an Act, I made the point that while we were talking about structures until the cows came home, the things that really mattered were the education and training of the staff within the NHS and the research element that gave those staff the very best tools in order to be able to care for patients and have good patient outcomes.
I compliment not only my noble friend, but the whole House, and indeed the whole Parliament, on the way in which it got behind the proposal in that Bill which is now in this one to create Health Education England as a way forward. The appointment of Sir Keith Pearson, who knows the supply side very well and has the ability to bring people together to listen to what he has to say and to be able to develop Health Education England as a real force for good, is quite outstanding. My worry is that we will start to bind the hands of Sir Keith and Health Education England, and we must not do that. What is required now is an organisation that is given sufficient flexibility and power to be able to grasp the key issues that are facing the NHS and to move forward.
I support very strongly the amendment in the names of the noble Lords, Lord Turnberg and Lord Patel, to include on the board people with relevant expertise. I am pleased that the noble Lord did not go on to say exactly who should be on that board, because I believe that that would be a step too far. But to have somebody with a real background in training, education and medical research would bring great strengths to the board.
I also support Amendment 3 in the name of the noble Lord, Lord Hunt. Indeed, I support virtually all the amendments tabled by the noble Lord and compliment him on the way in which he introduced this part of the Bill. Having a registered nurse on the board is so important. If we do nothing else in terms of the Francis report, the one thing that shines through is that you need somebody within the organisation who brings to the board those issues of quality care at every level. That is really quite exciting. I hope that my noble friend will listen to the wise words of the noble Lord, Lord Hunt, and others, and ensure that nursing is given a real place at the table, because quite frankly for generations it has not been. Nurses are no longer the handmaidens and “handmasters” of other professionals. They are in fact equals.
Baroness Emerton
My Lords, I support the noble Lords, Lord Hunt, Lord Turnberg and Lord Willis, in their recommendation that a registered nurse should be on the board.
An issue that Francis picked up after the report is that the nursing voices are not strong. He said he was disappointed in the response from the nurses. We now have to ensure that the nurses on the board are equipped with the knowledge and expertise to be able to speak out and hold their own. The training of senior nurses in standing at the board table and making their voices heard and understood on quality, safety and the patient experience is going to be very important. Therefore, it links very much with the leadership training, which we also need to address, in terms of their preparation. Perhaps the noble Earl will comment on that.
Lord Warner
My Lords, I support these amendments. I will pick up the point made by my noble friend Lord Hunt about managers. The public sector needs all the quality management it can get and many of its problems rest on the fact that we do not have a cadre of managers to take many of our public services through the difficult years ahead. The NHS is no exception.
For too long—and my own party has been guilty of it in the past—we have dismissed managers as men, and indeed women, in grey suits who are dispensable. We have to give some strong messages to HEE that if the NHS is to develop and evolve and cope with the problems ahead, we need a strong cadre of managers and we have to develop them over time. It is not too early to start now because we have a real problem not just in staffing chief executives now but in staffing the next cadre of chief executives and the middle management and development programmes for that. The Government would do well to give some strong messages to HEE and possibly even consider strengthening the legislation on this issue because it would be a missed opportunity if we do not strengthen that body of people to help us run the NHS in the coming decades.
Baroness Finlay of Llandaff
My Lords, I will briefly add my support, particularly to the amendment in the names of the noble Lords, Lord Turnberg and Lord Patel. I will draw the House’s attention to the wording, that it is,
“expertise in medical education and training”
that is being asked for, not just medical education, and that the expertise in research is not tied to medicine.
I understand the arguments that HEE must not be too tied or have a board that is too rigid, but if it is to meet the enormous challenges that it faces—and it has come from many, many discussions—to be able to have questions asked at board level about education and training will be essential if we are to have a workforce that can adapt rapidly as new technologies and new ways of providing care come along. It will need to have people with expertise and understanding of the most efficient and effective ways to upskill the workforce in particular areas, because there are enormous unknown challenges ahead.
Baroness Masham of Ilton
My Lords, I, too, support having a nurse on the board. It is vital because the nursing workforce is the biggest of all the professions, and training and recruitment is sometimes the problem that has to be faced.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we begin our Committee proceedings with a series of amendments that take us to the heart of the theme that permeates this Bill. The driving principle of reforming the education and training system is to improve care and outcomes for patients. Excellent health and healthcare require a training system that will deliver a highly skilled workforce, working together with compassion and respect for people.
Noble Lords will remember our debates of last year when, recognising the importance of education and training in the NHS and public health, we inserted into the Health and Social Care Act a clear duty on the Secretary of State to ensure that there is an effective education and training system. This Bill delegates that duty to Health Education England. This means that Health Education England will be clearly accountable to the Secretary of State for ensuring that there is an effective education and training system in place for healthcare workers in England. Health Education England will provide national leadership for workforce planning, the commissioning of education, training and development activity, and the quality assurance of the education and training that is delivered.
The backdrop to all that is the changing face of healthcare provision. The way health services are provided is expected to change significantly over the next few decades, with more care provided in the community and an increased emphasis on public health. This cannot happen unless we equip the workforce with the skills and knowledge to do this. To do it successfully, the local and national infrastructure needs to be in place to plan and commission effectively. That is why the creation of Health Education England and the local education and training boards is so important.
It is vital that the board of Health Education England has the necessary skills and experience to oversee the delivery of its important functions. In recognition of this, the Government have already strengthened the Bill, following pre-legislative scrutiny, to place an explicit requirement, in paragraph 2(1) of Schedule 5, on Health Education England to recruit members with clinical expertise. The specific nature and description of the expertise and specified numbers are to be set out in regulations. That amendment has been well received by stakeholders such as the Royal College of Surgeons. A similar requirement has been placed on local education and training boards to have members with clinical expertise.
The noble Lords, Lord Hunt and Lord Turnberg, have tabled a number of amendments relating to clinical expertise on the board of HEE and the LETBs. I realise that Amendment 1 is a probing amendment. It may be helpful to explain our thinking around the Schedule 5 requirement. This sub-paragraph was added to the Bill following pre-legislative scrutiny to place an explicit requirement on Health Education England to ensure that there is clinical expertise on the Health Education England board. It also responds to responses to the consultation on the Bill, which touched on the importance of Health Education England having access to professional leadership. This will give Parliament and bodies representing the professions the necessary assurance that the Health Education England board has access to the appropriate knowledge and understanding in making decisions that impact on professional education and training. It also provides the basis for a clear duty in the Bill for both the Secretary of State and Health Education England to make appointments of clinical experts, which can be developed subject to regulations. For example, the regulations will specify what we mean by “clinical expertise” and allow greater flexibility to specify any detailed requirements. It will also allow changes to be made to those requirements as Health Education England matures, should circumstances demand it.
Amendments 3 and 4 seek to extend the requirement for members with clinical expertise by expressly requiring Health Education England to include in its board membership a registered nurse and someone with experience in staff groups that are not professionally registered. Similarly, Amendment 2, tabled by the noble Lord, Lord Turnberg, seeks to extend the requirement for members with clinical expertise by expressly requiring Health Education England to include one or more members with expertise in research and one or more members with expertise in medical education and training in the Bill.
It is undoubtedly important for Health Education England to have access to professional expertise, but having said that I need to make clear that the Government do not believe that it is appropriate for the Bill to mandate requirements for certain professions or particular areas of expertise. That is better suited to be set out in secondary legislation, as it may change over time, and Health Education England will need greater flexibility to recruit the expertise it requires and to specify any detailed requirements as circumstances demand.
One of the great strengths of Health Education England over previous arrangements is that it has a remit for all the professions, bringing a strengthened approach to multi-professional education and training. Although medical and nurse training, and an understanding of the importance of research, are extremely important elements of its functions, HEE has a much broader focus. It may be helpful to the Committee to have a sense of how the new organisation intends to do justice to that broad remit.
First, HEE will employ a director of education and quality at board level who is responsible for ensuring a co-ordinated multi-professional approach to education and training. Within the Health Education England special health authority, that post is filled by a doctor, and is supported by a medical director, a director of nursing, and other professional advisers for dentistry, pharmacy, healthcare science and the allied health professions.
Secondly, Health Education England has established professional advisory groups, bringing together employers and national stakeholders, to focus on profession-specific education and training issues covering medicine, dentistry, nursing, pharmacy, healthcare science and the allied health professions. These advisory boards will support HEE and its board in the decisions they make that impact on health professional education and training. It should also be remembered that Health Education England employs many health professionals that support the activities of the LETBs. In these ways it has direct access to a wealth of knowledge and expertise on the planning, commissioning, provision and quality assurance of education and training.
The Government understand the importance of considering the support workforce that is not professionally registered. Health Education England, with the networks of employers working through the LETBs, will provide a wider leadership role in the development of the whole workforce engaged in the delivery of healthcare and public health. This is emphasised in the Government’s mandate for the Health Education England special health authority. In making non-executive appointments to the Health Education England board, the Secretary of State will source the skills and expertise that are required to ensure the Health Education England board can function effectively. The chair and non-executive directors will do likewise in making executive appointments to the board. That approach has worked well for the recruitment of the current HEE special health authority board, which has three members with clinical expertise, including a doctor. I should also mention that two non-executive appointments are still to be completed. In recruiting for those, we are looking for a further clinician with experience of equality and diversity issues, and someone who can bring a strengthened focus on the patient perspective to support the development of education and training.
In the light of what I have said, I hope noble Lords will feel reassured that the Health Education England board is suitably clinically informed, and that they will feel able to withdraw those amendments.
I now turn to Amendment 5. The Bill already requires the consent of the Secretary of State to the appointment of the chief executive of Health Education England. That approach is in line with the appointment of other chief executive officers across the health system and seems proportionate for a body of this size and nature. In addition to approving the appointment of the chief executive, the Secretary of State will appoint the chair and non-executive directors of Health Education England. This approach has worked well for the HEE special health authority, which has a board with a good blend of experience and expertise.
As for the role of Parliament, the Bill makes provision for Health Education England to report to Parliament on an annual basis, with the requirement to publish an annual report setting out its achievements and to publish annual accounts. I am sure the Health Select Committee will rightly continue to take a strong interest in education and training and will have the opportunity to discuss progress with Health Education England whenever necessary. I hope that will reassure the noble Lord on this amendment.
Ensuring that non-departmental public bodies have robust governance and accountability arrangements in place is clearly essential. Schedule 5 to the Bill makes provision for the constitution of Health Education England and deals with the exercise of its functions and its financial and accounting obligations. A number of amendments in this group fall under that broad heading.
Amendment 6, which again I realise is a probing amendment, poses a question about the terms of remuneration of HEE’s employees. In establishing HEE as a non-departmental public body, it is important that it is given the appropriate levels of autonomy and independence to carry out its important education and training functions without day-to-day interference from Ministers or the Department of Health. Yes, it needs to be held accountable for the use of its resources, and the Government are committed to holding it to account in an open and transparent way, but I hope noble Lords would agree that it is important for a body of this nature to have the ability to determine the pay and remuneration rates for the people it recruits and employs, including its executives. That does not mean that it will not be subject to any constraints. I can reassure the Committee that as an arm’s-length body of the Department of Health, HEE will be subject to the rules and controls covering the use of its budget, and to procedures applicable to senior appointments and levels of remuneration. These are the very same rules that apply to other arm’s-length bodies and to all government departments.
The noble Lord, Lord Hunt, asked me whether HEE employees will be engaged on NHS terms and conditions. In fact, HEE employees are currently employed on NHS terms and conditions and there are no plans to change that when HEE becomes an NDPB.
Amendment 7 is another probing amendment. The provision which the noble Lord has questioned is important. It clarifies that Health Education England’s property is not to be regarded as property of, or held on behalf of, the Crown. This is a standard provision that applies to other arm’s-length bodies in the health system. It allows Health Education England to make arrangements for its own property and office needs. It needs to do so to support the staff it employs nationally and across the local education and training boards. It would not be practical for any other body to hold this responsibility. Of course, Health Education England will work with other bodies to look for savings on estates, information technology, human resources and in other areas. It is already doing that as part of the shared services programme which the Department of Health and all its arm’s-length bodies are signed up to.
Part 2 of Schedule 5 imposes a very clear duty on Health Education England to exercise its functions effectively, efficiently and economically. Part 3 of Schedule 5 sets out how the Secretary of State will fund Health Education England and includes restrictions on the use of resources. These are consistent with provisions made for other bodies in the healthcare system such as NHS England.
I make the same point as I did a minute ago—that HEE needs to be held accountable for the use of its resources—but it is right to give it direct responsibility for how it operates and manages its day-to-day business, including the ability to make arrangements for its own property and accommodation. In the light of that, I hope the noble Lord will feel sufficiently reassured to not press his amendment.
Baroness Cumberlege
Perhaps I may comment on what my noble friend has said in reply to the debate. I understand that under secondary legislation he is considering putting a registered nurse on the board. Some assurance on that would be very helpful. In my experience working with clinical commissioning groups, when they were appointed there had to be a nurse on the board, and the last person to be appointed in many cases was the nurse. There was a feeling that it was hard to find a nurse who would make such a contribution. Some very talented young nurses are coming on-stream, but when one talks about a clinical presence on a board, so often, it is interpreted as a medical person on the board. We seek to ensure that a working nurse will be on those boards. If my noble friend can reassure me that he will consider that very carefully when drawing up the regulations, I will be very pleased.
I am so sorry. I should have declared an interest. My interests are on the Lords’ Register.
Earl Howe
My Lords, I listened with care to my noble friend, whose experience we respect greatly. I can tell her that Health Education England’s board will need to have access to a cross-section of clinical expertise, as it does at the moment. Nursing representation will of course be very important. I assure her that we will prioritise that issue in developing the supporting regulations on membership. That is probably as far as I can go, but I recognise the force of everything that my noble friend said.
Baroness Emerton
On a point of clarification, the Minister used the term multi-professional education in relation to integrated services. We have concentrated on medicine, nursing and clinical expertise. Because we are going to be looking across the boundaries into social care, is Health Education England going to have anything to do with the social care aspect of the training of clinical specialists? We have not mentioned social care, and I wondered whether we should.
Earl Howe
My Lords, Health Education England will have responsibility for the NHS workforce, but not for the social care workforce. We will reach a group of amendments that bear closely on the issue of integration, where I am sure that we can explore the relationship that Health Education England will have with those bodies charged with delivering the social care workforce. The noble Baroness is absolutely right: there needs to be co-ordination and joined-up thinking in those areas. If she will allow, we can wait until we reach that group of amendments before debating the issue further.
Lord Warner
Let me assure the noble Baroness that I shall be in good voice on the subject of social care on Amendment 13.
It was helpful to hear what the Minister had to say about advisory committees and advisers. I listened carefully. I did not note anything about those advisory committees or an adviser for what I might call the sub-professional group. I am sure that the professions will be extremely well looked after in HEE, but the groups which we often have the most problem recruiting and ensuring are properly trained are those below the professional level. Can the noble Earl say a little more about those unsung heroes working at the sub-professional level and what kind of advisory capacity HEE might have in that area?
Earl Howe
It will certainly be open to the board of HEE to establish an advisory committee that specialises in unregulated professions. Although, again, I cannot make a firm commitment about that, the very fact that we are dealing with a workforce of substantial size on which the NHS crucially depends—I am now talking about healthcare support workers—means that it would be very surprising indeed if the board were not to have some form of specialist advisory service to inform its decisions.
Lord Willis of Knaresborough
Before we finish debating this group of amendments, will my noble friend reflect on what he has just said about regulation? One of the traps we fell into with the Health and Social Care Bill—I do not think that it was intentional, it just happened—was that so much was promised in regulation that it was not until we started discussing the regulations that we saw what we had not done in the Bill. Perhaps it would be helpful to produce draft regulations as we go along before Report, so that we know what we are including in the regulations.
Earl Howe
It may not surprise my noble friend to know that I asked my officials the self-same question, because I anticipated an appetite for draft regulations. I am, unfortunately, not in a position to make that promise, much as I would like to do so, because there may not be the necessary time available for the regulations to be drawn up in draft. However, I will take back the strength of my noble friend’s request and see whether there can be any reconsideration of that point.
Lord Hunt of Kings Heath
My Lords, it has been a very good debate, and I am grateful to the noble Earl and other noble Lords for taking part. It is the role of noble Lords always to ask the Government for draft regulations but, alas, I fear that we may not see them. If we cannot, perhaps we could at least get a sense of instructions that might be given on policy direction.
First, let me say that the Government’s reflection on the Joint Committee’s recommendation with regard to clinical expertise, and the change that has been made, is welcome. I listened with care to the noble Earl when he said that the needs of Health Education England and the education and training of staff may change over time, which is why that is best left to regulation. That makes sense, but I cannot believe that there will ever be a time when research and nurse representation will not be important. I ask the noble Earl to give that further consideration.
I will just reflect on the comment of the noble Baroness, Lady Emerton, that this has been a consistent theme of restructurings over the years. The noble Baroness, Lady Cumberlege, and I have lived through many restructurings and they always start with the premise that there will not be a nurse on the board. Then, after argument and sometimes experience, it is discovered that you need to have a nurse. I would have thought that the Francis report, at its heart, focused a lot on nursing experience and leadership. I ask the noble Earl to give this further consideration. It would be a very visible sign that the Government are listening to this point and that they actually set out in primary legislation that a registered nurse should be appointed.
I am glad that the noble Earl picked up the point about non-registered staff and managerial staff. It is not just in the health service. In the further education sector there is a similar problem, with only a limited number of people applying to be college principals. We need to think very hard about what we can do to give greater support and encouragement to bright young people coming through so that they aspire to take on these top jobs. No one should underestimate the pressures that those leaders are under, but we really want good people. I endorse the noble Earl’s reference to clinicians. We need to encourage more clinicians to take on leadership roles.
I was very interested in the contrast between the desires of the noble Earl not to give autonomy to the board to appoint its own chief executive, but to give it autonomy when it came to the salaries of its staff. I ask for some consistency here. If the Secretary of State appoints the chair and the non-executives—which is absolutely right—he or she should then have confidence in their judgment to allow the board to appoint a chief executive.
Finally, on the intervention of the noble Baroness on integration, it might help our future debate if the noble Earl could confirm that Clause 88, on matters to which HEE must have regard and in which subsection (1)(h) refers to,
“the desirability of promoting the integration of health provision with health-related provision and care and support provision”,
answers the point that the noble Baroness raised—that in effect HEE does have to have an understanding of the needs of those providing social care because of the contribution that they can make to integrated services.
Lord Hunt of Kings Heath
My Lords, I am very grateful. Having said that, I beg leave to withdraw my amendment.
Lord Turnberg
Lord Turnberg
I will not move this amendment but I want to make one brief comment. If we are to rely on the regulations to interpret what clinical expertise really means, it is unlikely, however, that expertise in education and training will not be essential. I hope that comment will be borne in mind.