Care Quality Commission: Morecambe Bay Hospitals

Baroness Cumberlege Excerpts

Thursday 20th June 2013 Lords Chamber

[Earl Howe]

I am grateful to the noble Baroness. In fact, the trust has taken significant action in response to the concerns raised by the CQC and Monitor. In addition to responding specifically to the three warning notices issued by the CQC, there have been significant leadership changes at the trust. Sir David Henshaw was appointed as interim chair and Eric Morton as interim chief executive. The trust appointed four new non-executive directors and a new chief operating officer and recruited a new obstetric consultant and additional midwives. There have been other appointments as well. It has established a programme management office, as requested by Monitor, to oversee the implementation of programmes of work to bring about lasting improvements across the trust—and it has recruited a number of posts to the programme office to take that work forward. So I am encouraged that it is taking the position as seriously as it should in the circumstances and that, again, there is a refreshed team at the top of that organisation.

[Baroness Cumberlege]

Very often, when we have these inquiries, they are initiated not so much by the people who work within the trusts but by members of the public who feel very concerned about the quality of care being given within a hospital or service. Very often, those people who bring up these concerns, who are dubbed colloquially as whistleblowers, get very victimised by other people within the population but also within the hospital. Is there any support or help that we can give those people who bring to the attention of the NHS some of the problems that exist?

[Earl Howe]

My noble friend raises a key issue, which successive Governments have wrestled with. We all know how life works. Whistleblowers are treated badly because their message is often very uncomfortable. That is why local Healthwatch could potentially be a very important part of the puzzle here, by ensuring that people have a place to go to that they can trust and that can raise concerns without necessarily naming the person who has initiated those concerns.

More and more, we need to encourage providers of care to take ownership of their performance. They have to be candid with themselves and accept criticism where it is laid. Boards of directors have to look systematically and regularly at the complaints made against them—whether rightly or wrongly—to make sure that they are as open as possible with themselves. Only by instilling a culture of that kind can we move forward.

Care Bill [HL]

Baroness Cumberlege Excerpts

Wednesday 12th June 2013 Lords Chamber

[Lord MacKenzie of Culkein]

My Lords, I rise briefly to speak to Amendments 58C and 59. The noble Lord, Lord Hunt, and the noble Baroness, Lady Emerton, rightly referred to including nursing in the Bill.

As the noble Baroness, Lady Emerton, said, the practice of nursing these days is underpinned by research. Of necessity, nurses are involved in research, and it must be right to include the Nursing and Midwifery Council and the Chief Nursing Officer in the Bill.

In debates on the Bill, we have heard a number of times that it is all too easy to exclude nurses. Whatever body they should be represented on, they so often are not there. I can go back, probably the better part of 40 years, maybe more, to when I once had the temerity to ask my matron to raise something at the hospital management committee. She said to me, “I’m sorry, nurse, I can’t, because I only attend by invitation of the group secretary”.

There have probably been about 20 reorganisations—I forget how many—since those days. However, all too often the situation has not changed and nurses remain excluded. The reason for excluding them, very often, is that the legislation does not cover it and therefore it is not necessary for nurses to be included. We now have the opportunity. Let us have nursing in the Bill. If we are going to have lists, as the noble Lord, Lord Hunt, said, I want to see nurses in it. I hope that the Committee will support that.

[Baroness Cumberlege]

My Lords, I strongly support the amendment tabled by the noble Baroness, Lady Emerton, and am very interested in what the noble Lord, Lord MacKenzie, said. It seems that, over the years, nursing has been the poor relation when it comes to promoting the medical profession. Both are so important, and they have to work together. If the Francis report tells us anything, it is that we need to ensure that both are of a very high quality.

I asked the Royal College of Nursing today to give me some examples of research that nurses are doing. I will not try the patience of the Committee by going through them, but it gave me three extremely good examples which undoubtedly improve the quality of patients’ experiences and recovery rates. This work is going on, but it really should be of a higher profile. It should be applauded and used. I appreciate very much what the noble Lord, Lord Hunt, said about lists, which are a trap that I remember falling into on occasions when I was a Minister. I suspect that the noble Earl will tell us that we want to have it both ways: sometimes we want things in regulations because that is more flexible and at other times we want them in the Bill. This is something of a dilemma, but if the medical profession is in the Bill, nursing certainly should be as well.

I also strongly support Amendment 60, in the name of the noble Lord, Lord Turnberg. I was very interested to read about the delays that occur through not getting together all the different organisations that are going to be involved in a single trial. According to Kidney Research UK, the time taken in one trail to receive R&D permission varied from around five weeks to 29 weeks. A study of stroke survivors took between one week and 35 weeks to receive permission from the NHS trusts involved. The time taken between submission of site-specific information and NHS approval ranged from five weeks to 50 weeks for a multi-centre trial comparing two types of emergency intervention for ruptured aortic aneurysm. This is totally unacceptable. Those who are promoting the research, and are the leaders in it, must get so frustrated when the bureaucracy will not allow them to go ahead. We need good research. It makes a huge improvement to patients’ lives, especially, of course, when it is translated to the patient in the bed, as it were. Anything that we can do to speed this up and to put pressure on to ensure that the time lags are not as long as this would be very much welcomed.

[Lord Patel]

My Lords, I rise to support Amendments 59, 60, 61 and 62, to which I have put my name. It was very clever of the noble Lord, Lord Hunt of Kings Heath, to have an amendment about the medical royal colleges lead to a discussion on value-based pricing and the cancer drugs fund. I am tempted to have that debate because it may be much more interesting; it is an issue that we should debate at some stage. In responding to the previous amendment, the noble Earl highlighted the Government’s strong backing for life sciences. When we talk about value-based pricing, we must consider how we could reimburse cell-based therapy, which is not drug therapy, at what stage in the development of cell-based therapy reimbursement should kick in and what value would be put on different stages. That would be a good debate to have.

Moving on from that, I strongly support the amendment tabled by the noble Baroness, Lady Emerton, on the inclusion of the Chief Nursing Officer. I also support her in asking why Health Education England does not have a nurse education director. If the nursing workforce is the largest health workforce in the NHS and does not have a nurse education directive, something is missing and needs to be replaced.

Care Bill [HL]

Baroness Cumberlege Excerpts

Monday 10th June 2013 Lords Chamber

[Baroness Cumberlege]

My Lords, I congratulate the noble Baroness on the enormous amount of work that has clearly gone into this amendment and on the way that she introduced it, drawing on a lifetime’s experience in this field. My one reservation is about having to consider what the fundamental purpose of Health Education England is. As I see it, if HEE works well, then in future it will be the engine that delivers a better healthcare workforce in England, thereby improving the quality of care for patients. It is responsible for the education, training and personal development of all NHS staff and for recruiting, from our schools and into our universities, suitable people to carry on these tasks within the NHS. It is employer-led and it is there to provide the right workforce with the right skills and values, in the right place and at the right time, to better meet the needs and wants of patients.

The NHS has more than 300 different specific jobs and more than 1,000 employers nationwide, and the workforce needs to be educated and trained to exacting standards. Its task now is to prepare students for a very different NHS in the future: more care out of hospitals, more focus on long-term conditions, greater integration of health and social care, and new technology and techniques, all of which require planning and changes to curricula, as well as more of a focus on student choice towards NHS needs. It has an enormously difficult and comprehensive job to do. As I understand it, Health Education England accepts and supports the concept of mandatory training for healthcare assistants and the introduction of some sort of certification scheme that would allow HCAs to prove that they had attained the required levels of education and training.

It is a matter for Parliament to decide a view on regulation that goes beyond that recommended by the Government, but I do not believe that Health Education England would be an appropriate regulator. It is not created to have such a role, and that would not sit effectively with its core role of education and training. Therefore, although I very much understand the spirit of the noble Baroness’s amendment and appreciate the knowledge that she brings to the subject, I do not think that HEE is actually the tool to do this with.

[Lord Turnberg]

My Lords, I, too, welcome the principle behind the noble Baroness’s Amendment 16 but I agree with the noble Baroness, Lady Cumberlege, that Health Education England may not be the right place for this. At various times in our debates I have banged on about the regulation of healthcare assistants, because not only would it reassure employers and patients that standards were being met but being on a register gives individuals a degree of self-respect and sense of identity and it boosts their morale. In a way, it is a pity that we got rid of state enrolled nurses some time ago when we moved to university-educated nurses. In effect, that has been very successful and nurses have done very well—they do a marvellous job—but we have left a gap where the SENs were.

Amendment 23, which moves slightly along this same route, may be as far as we can go but, if we do have mandatory training, that will inevitably mean that someone has to produce a register of those who have received such training. This may not be quite the right place for it but we might get there by another route.

Health: Midwives

Baroness Cumberlege Excerpts

Monday 10th June 2013 Lords Chamber

Asked By

[Baroness Cumberlege]

To ask Her Majesty’s Government what action they are taking to ensure that independent midwives can continue to work with clinical indemnity.

[Baroness Cumberlege]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In doing so, I declare the interests that are on the Lords’ register and, in this instance, the unremunerative position as patron of Independent Midwives UK.

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

My Lords, a 12-week consultation on the legislation to require regulated healthcare professionals to hold indemnity or insurance closed on 17 May. We are now analysing the responses to assess how the issues might be addressed, including those affecting independent midwives—that is, self-employed individuals in the private sector. This includes consideration of different models of service. Officials are also facilitating meetings between NHS England and representatives of independent midwives to discuss emerging commissioning issues.

[Baroness Cumberlege]

My Lords, I thank my noble friend for that Answer. On 26 October, when the European directive comes into force, it will preclude around 170 independent midwives from practising, and this at a time when we have a burgeoning baby boom. Many of these midwives actually work within the NHS. Is my noble friend aware that many of these independent midwives are seeking a solution but they require help, advice and support from the department and, above all, a revision of the tariff for maternity services? Will my noble friend ensure that this issue is a priority for urgent action by his colleagues, the Department of Health and the other agencies involved?

[Earl Howe]

My Lords, as my noble friend knows, work has been going on for a number of years, including going back to the previous Government, to see whether there are viable ways of ensuring that this small group of independent midwives can obtain suitable indemnity or insurance cover. One of the difficulties we have had is the absence of information on the potential barriers to independent midwives moving to alternative governance and delivery practices in order to obtain that cover—hence the consultation I have spoken about. As I said, we are now analysing the responses. However, I do not agree that there is no way through. We know that some independent practitioners have opted for a corporate or social enterprise model as a way of gaining insurance cover. We are trying to understand what the barriers are to that among those who are resisting the idea.

Care Bill [HL]

Baroness Cumberlege Excerpts

Monday 10th June 2013 Lords Chamber

[Baroness Pitkeathley]

I speak in support of Amendment 51 on the patient and carer voice. I know that there is sometimes resistance to patient and carer representatives on bodies such as this. One often hears professionals say, “They only speak from their own experience”. Yes, they do speak from their own experience—and that is actually the powerful and most informative bit. That is not to say that patients and carers can only speak from their own personal experience; they speak from the wider experience too of other patients and carers with whom they are in contact. That is the most important voice and we should give it a hearing, because very often it is a way of approaching a situation entirely differently from the way in which the professionals would come at it. I am sure that there is a great deal that most professionals, either trained or in the process of being trained, could learn from that.

[Baroness Cumberlege]

My Lords, I wish to say a word about these issues. There is a danger, when we are setting up on the face of the Bill, the component parts of something like the LETB boards. As I understand it, the principle was that the majority of members of the board are local providers. That seems sensible because clearly they are the people who are going to have the knowledge and will inform the LETBs. Simply adding new members, each with a representative function, does not really aid the ability of a board to make decisions. It can become less effective and efficient, purely due to the numbers of people around the table.

There are many groups of workers and, indeed, patients who have got a case, but there are other ways of involving them. I very much accept what the noble Lord, Lord Turnberg, said about having due regard to universities and deans of medical schools. I am happy about the idea that one should have regard to advice that has been given, but I am not sure about having specific representatives that HEE decides are good for a local area on the board. Some areas want to do it differently. To me, that is fine. The size of the LETBs varies enormously; they can be the size of the whole of the north-west and the whole of the south-west, yet Wessex and Thames Valley are separate. These are to be local education and training boards; they need the freedom and flexibility to reflect the local area. Although I understand that people are anxious to ensure that the LETBs are efficient and represent local areas, views and constituent parts, it should be left to their flexibility and judgment.

[Lord Patel]

My Lords, I support Amendments 38 and 41 in the name of the noble Lord, Lord Turnberg. I slightly disagree, which is difficult to do, with the noble Baroness, Lady Cumberlege. In the new world, postgraduate deans are responsible not just for medical education, but for the whole of health education. If Health Education England is to be a body that influences education and training from the beginning to the end—we will come to another amendment relating to continuous professional development—postgraduate deans and deans of medical and nursing schools are crucial. If they are not to be represented on the local education and training boards, Health Education England cannot, through its committee, influence any of the innovations in education and training. That would be wrong.

There are examples where postgraduate deans and deans of medical and nursing schools are represented on education and training boards and they work fantastically well. I cannot see any reason why postgraduate deans and deans of nursing and medical schools could not be represented on local education and training boards, no matter what their size. I support the amendment.

--- Later in debate ---

[Baroness Hollins]

My Lords, my interest is as the parent of two adult disabled children who receive publicly funded care. I did not speak to the earlier amendment on the need for the regulation of health and social care assistants, but I strongly believe that some such staff are currently poorly served by the lack of an adequate professional framework. Many have poor pay and variable conditions of work, and perhaps poor protection for themselves. They also have varying access to training, supervision and education.

To give one example, a care assistant was employed to work with an autistic person without receiving any autism-specific training, even though it was specified in a support plan. One would hope for some basic mandatory training that also specified what future training might be needed to support specific people with specific needs. That seems to be common sense.

My noble friend asked clearly for mandatory training in basic standards of care, and that these candidates should then be registered as suitably trained. It is a neat solution to the problems that we are facing and it makes very good sense. I have one more example: in the interests of more integrated health and social care, care assistants are often required to support disabled or elderly people to access healthcare, but they are not very good at doing that. The confidential inquiry into the premature deaths of people with learning disabilities found that it was often the lack of persistence of people who were supposed to be supporting learning-disabled people that led to a failure in follow-through of their healthcare investigations and treatment.

I have a question about how personal assistants employed directly by people who are in receipt of direct payments would fare under such a system. Disabled people would need assurance that the personal assistant applying to work with them also had basic skills. One would hope that disabled people employing personal assistants would be reassured by the knowledge that someone had been registered as having a certificate of basic standards of care. I add my support to these very good amendments, particularly Amendment 23A.

[Baroness Cumberlege]

My Lords, I support these amendments on mandatory training. I know that the noble Baroness, Lady Emerton, has fought and fought for this. I served with her on the United Kingdom central council for nursing, midwifery and whatever it was. She pioneered the whole idea of improving nurse training, and it was very successful.

To follow on from the noble Baroness, Lady Hollins, it is interesting that we now have two different parts to the arguments. One concerns the benefit to patients and the public, while the other concerns the benefit to the workers themselves, which I thought was a very interesting angle. It was Terry Leahy who said that he built his empire just by ensuring that all who worked for him felt good about themselves, and I thought that that was very interesting.

I am concerned about how the amendments are fashioned because I am not quite sure what we are talking about. Perhaps the noble Baroness or the noble Lord, Lord Patel, will clarify that for me. We talked about healthcare support workers, and I understand that such workers predominantly work in the NHS. However, subsection (2) of the proposed new clause refers to,

“a health or care support worker”.

I am not sure what a care support worker is, as opposed to a healthcare support worker. Does the support worker work, as the noble Baroness, Lady Hollins, said, in people’s homes? Do they work in residential care? Are they covered by this or not?

The noble Baroness made another point, which I was also going to raise and on which I would like some clarification: what about the people who work for others who need care, through direct payments or personal budgets? Will this rule out those volunteers who often come in and sit with someone, who may do some minor tasks and may even do some relatively nursing-style tasks, such as putting in eye drops, which a member of the family would do? I should like to clarify who we are talking about.

[Lord Hunt of Kings Heath]

My Lords, like my noble friend Lord Campbell-Savours, I remain puzzled by the Government’s approach. I am grateful to the noble Baroness, Lady Emerton, for setting out a number of persuasive arguments for why there ought to be mandatory training for health and care support workers. There seems to be a general consensus around the House and no doubt the Minister will agree with it. My reason for supporting the amendment is that mandatory training is clearly very important, but it is inevitable that if you have mandatory training you have regulation; the two run together. Those who are proposing these amendments ought to recognise that there is an inevitability that if you have training then you must have a list of people who are trained; action has to be taken against those people who have been trained but are then found to be unsafe in dealing with vulnerable people; and there has to be a way of removing them from the list of those who have been trained that has been published. If you go down this route, one way or another you are clearly signing up to mandatory regulation, and a jolly good thing too.

Amendment 23A puts forward an eminently sensible suggestion for healthcare support workers to be certified to show that they have been trained in basic standards, with employers to register individuals who hold such certificates. We need to go back to the Francis report. Mr Francis is widely reported to be disappointed with the Government’s response to his report, and it is not hard to see why. His report commented on the absence of minimum standards in training and competence. This is compounded by huge variations in the approach of employers to job specifications, supervision and training requirements. That is why my noble friend Lord Campbell-Savours has come across so many instances of poor-quality healthcare support.

The Prime Minister’s Commission on the Future of Nursing and Midwifery noted that training for support workers was very variable and recommended that they should be better trained. In response, as the noble Earl told us earlier, the Government have commissioned Skills for Health and Skills for Care to work together to develop a code of conduct and minimum induction and training standards. We now know from the mandate issued by the Secretary of State to Health Education England that it is obliged to establish minimum training standards for healthcare assistants by spring 2014. At this point, I ask the noble Earl: how far does that go? Will it be mandatory for all entrants to the role of healthcare assistant to undertake such training? If that is so, will this extend to care assistants? What about existing health and care support workers? Will this training extend to them, or will it apply only to new people coming into the healthcare profession?

Under the proposals, how will employers know if their support workers have undertaken the minimum standard of training? Will a nationally recognised certificate be issued? Will a national list be established, indicating those who have undertaken such training? If there is not a list, does that not leave a big burden on employers seeking to check whether prospective staff have undertaken the minimum training requirement under the mandate? I come back to the point I made at the beginning: if a list is established, would that, in essence, not amount to a register? If there is such a list or register and it becomes clear that a support worker is unsuitable to care for vulnerable people, is there a way in which an organisation or employer could then apply to have such an individual removed from the list of people who have received the minimum level of training?

Having a certificate showing that someone has achieved a minimum level of training will be generally regarded as a certificate of an ability to practise. If there is such a certificate, there must be a way to remove that certificate if people are found to be wanting. In effect, once one begins to lay down minimum standards and to specify mandatory training, will there not be an inevitable step towards regulation? Amendment 23A poses those questions to the noble Earl. I hope that he will answer sympathetically.

Care Bill [HL]

Baroness Cumberlege Excerpts

Tuesday 4th June 2013 Lords Chamber

The noble Lords, Lord Hunt and Lord Warner, asked specifically about the training of managers. Health Education England will work with the NHS Leadership Academy, which supports the development of managers and will take an interest particularly in the development of clinicians as managers. We are the first to agree with the noble Lord, Lord Warner, that managerial skills in the new NHS, as in the past, will be crucial if we are to deliver what we all want, which is a health service that is efficient, effective and delivers good outcomes for patients.

[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.

National Health Service (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013

Baroness Cumberlege Excerpts

Wednesday 24th April 2013 Lords Chamber

If the Prayer to Annul finds favour with the House, will the regulations be replaced by a new set with a key difference being different wording in Regulation 5 to make it clear that commissioners will be free to commission services in the way they consider best? Should the Prayer to Annul be rejected, what steps will Ministers take to ensure that the assurances are clearly understood across the NHS? One of the concerns of the House of Lords Secondary Legislation Scrutiny Committee was that Ministers have not clearly communicated their intention and that this may lead to imperfect achievement of their policy objective. It is therefore crucial for the Government to demonstrate their intention. What concrete actions will be taken now to communicate their intention? Finally, will the Government commit to reviewing how the regulations work in practice and to looking at the regulations again if they are not working in the way that they say they will?

[Baroness Cumberlege]

My Lords, I start by declaring an interest. My interests are in the Lords’ Register, but I particularly want to declare the two companies which I control, run and support. They do not provide treatment and care to the NHS, but they do provide training opportunities to NHS staff. I am also involved with a number of charities and voluntary organisations. I think that the Health and Social Care Act offers huge opportunities to the NHS. In this country, we have so much good will, so much talent, so many skills within the NHS but also without the NHS, in voluntary organisations and in the independent sector.

The noble Lord, Lord Warner, talked about 30 years of experience in social care. The NHS is no stranger to competition or how to handle it. Would-be doctors compete for medical schools. Qualified doctors compete for the very best jobs within the NHS. NHS hospitals compete with private practice for consultants’ time, and they also compete with non-healthcare employers to retain nurses. GPs have partly competed for NHS patients since 1948, and so have hospitals since 1991. Companies compete to provide the NHS with new medicines and diagnostics, NHS researchers compete for grants, and the NHS competes with schools, prisons and the armed forces for public funding. So I make the point that competition in the NHS is not only long-standing, but it is actually inevitable.

[Baroness Kennedy of The Shaws]

If I may, I point out to the noble Baroness that competition of course exists in all parts of our lives. There is something different about competition when profit is one of the considerations, and that is what concerns the public here. The concern is that we are talking about people making a profit who are offering to do so by cutting things to the bone, and competing with others whose commitment is public service. That is what concerns people.

[Baroness Cumberlege]

My Lords, we could have a whole debate on profit. Every person who sells their talents and does work has to profit. You cannot live without a profit unless you are receiving social care. Profit, of course, funds all our pensions, and a whole lot of other things—but I do not want to go into all that, because I think it is irrelevant to this debate.

I think that we should just look at what the private, independent sector does at the moment. South London, a very stressed area, has had a lot of problems with hospitals not having enough capacity. The Labour Government introduced urgent care centres, and they were introduced into south London. It is interesting to see that the regulator, the Care Quality Commission, recently described the service as first class; it is open seven days a week, from eight until eight. Better still, it was described by one of its users as the,

“best NHS experience I have ever had in my life”.

I am sure that that person was not only right about the experience but right that, whoever provides the service, it is the NHS—for it is the NHS that has paid for it through a contract. So privatisation is not about the provider; it is about reaching into your wallet to pay for the service for which the state should pay. That is the fundamental ethic of the NHS.

In southern England, an independent provider has ensured that 99% of target patients are screened for breast cancer, which compares with the national average of 77%. The provider also invested £4 million in new technology for outreach services. My third example—and I could go through lots—is in the north-east, where an independent provider of sexual health services has been able to screen 35% of 15-24 year-olds for chlamydia, which is significantly higher than the national average of 24%. It also saved commissioners money by reducing duplication across services.

[Baroness Young of Old Scone]

I am sorry to interrupt at this time of night, but I am conscious of the fact that the noble Baroness is citing lots of examples of where private sector provision and competition has produced good results. Is she equally aware that the Care Quality Commission had to remove two licences from urgent care providers for an inadequate service that could not be allowed to be sustained for even a few days longer after it was detected? They are not all success stories, by any means.

[Baroness Cumberlege]

My Lords, of course I accept that. We accept that in the NHS, do we not? You have only to look at the recent inquiries to know that the NHS is not perfect. What I am trying to put over is that by using a wider range of providers you can improve services for the NHS, but of course you need regulation and somebody ensuring that the quality is high. It is not perfect in all cases—of course I accept that—but it is not perfect in the NHS either. I do not think that any of your Lordships would not rejoice in better services that enhance patient care being provided. That is what we are all about. My view is that competition involves not a yes/no ideological choice but a pragmatic and nuanced judgment about how, or whether, to make use of it.

That is what brings me on to these regulations. There is much in them that will strengthen the NHS. I do not want to see them annulled or to see another delay. The NHS has been in something of a difficulty with all the changes that are being made, and it is now time to settle down and get on with it. So I do not want to see further delay. On the detail of the regulations, first and foremost I think that Regulation 2 of Part 2, which sets out the procurement objectives, is very good. It says—and I paraphrase a little—that NHS England and CCGs, when procuring healthcare services, must consider the needs of the people who use the services. So it is not about the staff but about the needs of the people who use the services.

There is a lot of rhetoric, as there has been for years, about putting patients first. However, we know that that rhetoric is not always put into practice. Again, I refer to some of the recent inquiries that we have had. In fact, we should be very concerned, as is the King’s Fund, that the UK has the second highest rate of mortality amenable to healthcare of 16 high-income countries. We should be deeply worried that we have the second highest death rate among those comparable countries. The NHS does need to change and improve. The think tanks and the people who think endlessly about the NHS all agree that it needs change. The Labour Party agrees that it needs change. The debate is about how to do it.

Regulation 2(b) refers to,

“improving the quality of the services”,

as the purpose of the legislation. Surely that is what we all want. Poor care is very expensive. It involves returning to hospital to put right what has gone wrong in the first place, litigation, poor staff morale and misery for users, families and friends. Regulation 2(c) is about efficiency. We all have a duty to ensure that money is not wasted and services are efficient. The noble Baroness, Lady Hollins, has just talked about that and what we need to do to ensure that we have commissioners of the highest order. Surely that is what we are trying to achieve.

Health: Midwives

Baroness Cumberlege Excerpts

Monday 25th February 2013 Lords Chamber

Asked By

[Baroness Cumberlege]

To ask Her Majesty’s Government, in the light of the continuing increase in births, what is their response to the recent report by the Royal College of Midwives, which states that there is a shortage of around 5,000 midwives.

[Baroness Cumberlege]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In so doing, I declare an interest as a fellow and vice-president of the Royal College of Midwives. My other interests are in the Lords register.

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

My Lords, there are some 1,381 more midwives in the NHS than there were in May 2010, and there are a record 5,000 in training. The Government have committed to ensuring that the number of midwives matches the needs of the birth rate. Most women already have choice and one-to-one maternity care, and we are working closely with the Royal College of Midwives to ensure that personalised, one-to-one maternity care is available for every woman across the country.

[Baroness Cumberlege]

My Lords, I thank my noble friend for that very encouraging reply. I suspect that every single Member of your Lordships’ House has been touched by a midwife. They are a remarkable and very committed profession. Is my noble friend aware that although there is what the Royal College of Midwives describes as a tipping point in the increase in the number of midwives attending women in labour, the real crisis is in postnatal care, where new mothers require advice, support and help in cherishing and feeding their newborn baby? Is he also aware that this requires continuity of a midwife? He has just told us that continuity is being carried through, but a recent survey shows that 40% of new mothers always see a different midwife. How does he propose that we put this situation right?

[Earl Howe]

My Lords, women should expect to have one-to-one care from a midwife during labour, birth and immediately after birth, and to continue to have the support of their midwife after the birth. This is especially important for those women who are susceptible to, or have, depression during pregnancy or postnatal depression. My noble friend is absolutely right about continuity. This depends on each woman having an individualised postnatal plan of care, taking into account her circumstances. To assist the NHS, the department has asked the National Institute for Health and Clinical Excellence to develop a quality standard for postnatal care, which it is anticipated will be published in July this year.

NHS Bodies and Local Authorities (Partnership Arrangements, Care Trusts, Public Health and Local Healthwatch) Regulations 2012

Baroness Cumberlege Excerpts

Tuesday 5th February 2013 Lords Chamber

[Baroness Masham of Ilton]

My Lords, it is with regret that we are here this evening regretting that the Government have, through restrictions on campaigning, deliberately tied the hands of local Healthwatch bodies from giving public voice to those patients’ interests.

The regulations seem muddled and unclear. I am surprised that the noble Earl, Lord Howe, has not managed to do better. Over the years, he has witnessed the difficulties that the bodies representing patients have had, ever since the closure of the community health councils. This time around, I feel that the Government are missing an opportunity. I support the view—I always have—that it is essential that local Healthwatch be independent and led by the service users and the public if it is to have credibility and influence. It must not be a tool of those whom it monitors and inspects.

With the Francis report to be published tomorrow, I am sure that it will become evident that a clear, independent voice supporting patients and users of care homes is vital. There should be trust. The dangerous culture of cover-up and not listening to family and friends must be rectified. At the moment, the Patients Association is asked to comment when there is a problem. We need good, dynamic Healthwatches to ensure that disasters do not happen. We need people who know the needs of their local population. We need safety and a good standard of all health and social care. Healthwatch England is there to help and support local groups, but the local Healthwatch should have freedom to do the very best for those whom it should be protecting and supporting. I hope that the Government will realise what is needed and do better before it is too late.

[Baroness Cumberlege]

My Lords, I suspect that my noble friend has got the message now that we are not totally enamoured of these regulations. I think back to when we had the White Paper, which was published in July 2010. I remember, as my noble friend Lady Jolly has said, how excited I was then by the fact that in local Healthwatch we were to have an organisation that really would be the collective voice of patients. There was a mechanism so that it would have a very strong infrastructure at the local level.

So far so good, but throughout the passage of the Bill Members of your Lordships’ House fought strongly to get that policy enacted. We were given assurances, as noble Lords have said, and they were given in good faith. Yet now we have the regulations in this statutory instrument, we are not only disappointed but deeply concerned. I share the grave concern of the House’s Secondary Legislation Scrutiny Committee, which says that there is a very real possibility that local Healthwatch is in danger of being manipulated, but our concerns do not stop there.

The Government are right to want local people to have control of local Healthwatch but there is a genuine fear about it being subjected to such complex and draconian restrictions on what it will be able to say and do. It is not entirely clear to us what value local Healthwatch can add to the accountability framework of the NHS. This view is shared by Healthwatch England which, as the noble Lord, Lord Collins, has said, suggests that this could be dealt with by guidance. However, the trouble with guidance is that it does not have any statutory force. However, it could use its powers to sharpen the way in which local Healthwatch operates—as an independent champion through the trademark which all local Healthwatches must have and have to own. I have not given my noble friend any notice of this, but perhaps he might like to think about that and take it away.

Paragraph 36 of the regulations prohibits local Healthwatch from opposing or promoting changes to any national or EU law, any national policy, any policy by a local public authority—including both local authorities, the NHS or “any organ or agency” of either—and any planned or actual changes in any of these. In addition, it prohibits influencing,

“voters in relation to any election or referendum”.

These prohibited activities may be undertaken only if they are incidental to what could be called the core purpose of local Healthwatch—that is, giving people a say in local health and social care—unless that core purpose is incidental to the prohibited activities. This is mind-stretching. That seems to be something of a circular definition whereby X is allowed if it is incidental to Y, unless Y is incidental to X. This is pretty difficult. I have said that it is mind-stretching but I really fear that it will be unworkable. What is certain is that it will be incomprehensible to local people, who are expected to participate in local Healthwatch.

The impact of this provision is likely to have a chilling effect and to negate the aims of Healthwatch. Why should any committed volunteer get involved in local Healthwatch, giving freely of their time and energy to try to influence things for the better, if they risk being penalised for doing so?

I shall describe three situations to the Minister to test this with him, and I hope that he will reassure me on these points. First, say that there was a controversial policy to close an A&E department in order to save money. Would local Healthwatch be permitted to provide evidence to campaigners of how good the patient experiences had been at that threatened department? Would that be banned under Regulation 36 as the promotion of changes to a policy that a public authority proposes to adopt? If the Minister says no, how could local Healthwatch be confident that the local NHS decision-makers would share this view?

Secondly, could people who had been active in a national campaign to improve quality and accountability in the NHS be decision-makers in local Healthwatch? Would local Healthwatch have to avoid any connections to an organisation seen as intending,

“to affect public support for a political party”,

that was in power? Again, if the Minister says no, and decisions on such matters are to be delegated to local authorities, how could local Healthwatch be confident of that?

Thirdly, during a local election campaign, would local Healthwatch be subject to purdah, like democratically elected bodies such as local authorities or the Government themselves? Would that apply even if it discovered serious abuses of vulnerable people with learning disabilities in a residential home during this period? Such a discovery would not reflect well on the local authority commissioners, who are “an organ or agency” of local government under the regulations. Would the local Healthwatch have to keep such concerns secret or risk being penalised by that very same local authority?

The very fact that we have to ask these questions demonstrates that we do not have the right set of safeguards for the independence of local Healthwatch. The fact that local Healthwatch is funded and controlled by local authorities, which it is supposed to be scrutinising, is pretty uncomfortable. The added constraints of Regulation 36 threaten its freedom to speak and to act in the interests of patients and the population. These very complex restrictions seem designed to protect those in politics or in the provision of services who have something to hide. They impoverish the debate on health and social care, whether it is about controversial reconfigurations or a Baby P tragedy. Patients could not care less about politics and just want someone to speak up for them when they themselves cannot.

I urge my noble friend to consider modifying, redrafting or, if possible, removing these restrictions, or to find a mechanism to ensure that they are not implemented in the way that I have outlined and the way that I fear. To me, it is not clear whom they are really designed to protect, but I fear that it is certainly not patients.

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

My Lords, I thank the noble Lord, Lord Collins, for raising his concerns and other noble Lords for following in his footsteps in sometimes very trenchant terms. A number of concerns have been raised about these regulations during the course of the debate and I will now do my best to address them in turn. A number of noble Lords reminded us of the critical importance of lay involvement in local Healthwatch and questioned why the wording of the regulations does not therefore prohibit employees of a local authority or indeed of the NHS from taking roles in the leadership and governance of a local Healthwatch. Indeed, your Lordships’ scrutiny committee suggested that this might leave a local Healthwatch in some way vulnerable to manipulation or threaten its independence. That concern was picked up by one or two noble Lords. I can, I hope, provide reassurance on this. Indeed, I am sorry that despite the department’s clarificatory submission to the scrutiny committee, it still remains a source of concern.

We completely recognise the importance of local Healthwatch being truly local organisations that are led by local people and involve volunteers. That policy aim is reflected in the way the regulations are drafted. They impose explicit requirements relating to the involvement of lay persons and volunteers. Both those terms are defined. The definitions of “lay” and “volunteer” are designed to be as inclusive as possible. Essentially, they aim to cover those who wish to give up their time for something they feel passionately about to influence change and service improvement. In practice, very often lay people and volunteers are the same group of people, but we thought it important not to frame a definition in a way that would exclude other people who might not define themselves in precisely those terms. The definition should, and does, apply as much to those who have paid jobs but who wish to do their bit for the community in their spare time as to those who do not work or who are retired.

Nursing Quality and Compassion: The Future of Nursing Education

Baroness Cumberlege Excerpts

Tuesday 11th December 2012 Grand Committee

[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.