Health and Social Care Bill

Baroness Emerton Excerpts

Tuesday 11th October 2011 Lords Chamber

[Baroness Emerton]

My Lords, I thank the noble Lord, Lord Warner, for mentioning integration because, as my notes say, the recent Dilnot report findings and the title of this Bill—health and social care—are the chance in a lifetime for us really to grasp this in terms of crossing the boundaries between health and social care, particularly the boundaries with local government which are sometimes difficult to close, which really is necessary for the elderly, frail and infirm.

We have heard a lot this morning and afternoon about the details. There is no doubt that the devil is in the detail. I am quite sure that the House will scrutinise the Bill in the forthcoming weeks and that we will be able to come to a consensus view. I declare an interest as a long retired nurse and a fellow of the Royal College of Nursing. Apart from the noble Baroness, Lady Masham, who has raised the issue of support workers, we have not mentioned nursing much this morning or afternoon. I want to raise three things: the challenge that is currently being faced out there in the field with the Nicholson £20 billion savings, the cost of the new structural recommendations and the effect that they are having.

The Royal College of Nursing is already reporting large reductions in numbers of staff, which are not being replaced by nursing posts, and that specialist nurses are being redeployed from their nursing posts to do other duties. Thus, the patients who require the specialist nurse—particularly in breast cancer, multiple sclerosis and all the others—are suffering the loss of their nurses. Where there is no support available by family or friends, an integrated pathway leads from primary care, secondary care, tertiary care back to secondary care, primary care and social care. It does not favour the experience of an 84 year-old with very little mobility recovering from quite a severe stroke to be discharged on a Friday evening at 6 pm to an empty house, with the only toilet upstairs and nobody to care for her until Monday morning.

The Royal College of Nursing has demonstrated that where costs being driven down becomes an overriding factor and corners are cut at the expense of the quality of service delivery, as sadly demonstrated in the Maidstone, Tunbridge Wells and the Mid Staffordshire foundation trusts, patient outcomes and even safety come into danger. This also affects the culture within the organisation, where fear begins to take over. Incontrovertible research evidence from independent academics across the United Kingdom, the United States and Australia show the relationship between patient outcomes and registered nurse staffing levels. In order to guard against the possibility of further tragedies and failures in the management of correct nursing staff levels upon the wards, the Royal College of Nursing would like to see the Bill amended to include mandated staffing ratios and levels. The national Commissioning Board would specify guidelines and the registered to non-registered ratio would not fall below 55 registered nurses to 35 non-registered, and, on the higher dependency wards, 65 to 35. The local CCGs would also monitor and assess compliance and efficiency. The RCN would also like to see these staffing levels and ratios as set standards to be taken into account by Monitor and the CQC.

I now move to Part 7 of the Bill and Clause 231, which my noble friend Lady Masham has already mentioned. I want to explain in a little more detail what the Nursing and Midwifery Council feels is necessary. The council recognises that the Government have accepted that unregulated workers supporting healthcare professionals represent a risk to public protection that needs to be addressed through regulation. The suggestion of voluntary registers may provide a solution for some healthcare regulators but the NMC believes that voluntary registration for healthcare support workers carrying out tasks delegated by nurses and midwives is not sufficient to protect the public.

Clause 231 gives no indication that a voluntary system will be underpinned by consistent UK-wide standards of training that would assure the public and employers that health support workers have the knowledge and skill they need to practise safely. The NMC believes that a voluntary system would do little to prevent cases of serious abuse and failure by health service workers such as those illustrated earlier this year at Winterbourne View and in the Parliamentary and Health Service Ombudsman report Care and Compassion?. Only mandatory registration can provide the statutory powers that the NMC needs in order to take action against health support workers who pose a risk to the public.

The House of Commons Health Committee was unequivocal in its support for mandatory regulation. Its seventh report on the annual accountability hearing with the Nursing and Midwifery Council states:

“The Committee endorses mandatory statutory regulation of healthcare assistants and support workers and we believe that this is the only approach which maximises public protection”.

The Royal College of Nursing supports the regulation of healthcare assistants and support workers. I know that many noble Lords do too and that the public would support this. The Bill proposes the abolition of the 10 English SHAs. In so doing, the Government will need to take into account that the SHAs currently host the local supervising authorities’ independent organisations responsible for ensuring that the statutory supervision of midwives is undertaken according to Nursing and Midwifery Council standards. We know that there have already been problems with the delivery of midwifery in some areas and the local supervising authorities play an important part in controlling standards. Any changes in the hosting and function of the local supervising authorities may necessitate legislative changes to the Nursing and Midwifery Order 2001 and the Midwives Rules and Standards.

On education and training, in their response to the NHS Future Forum report the Government stated that they will introduce an explicit duty on the Secretary of State to develop a system of professional education and training as part of a comprehensive health service. That will be crucial. However I urge the Government, when drafting the amendment, to consider the need for the Secretary of State to promote multi-professional education and training to ensure that the NHS can continue to develop a high-quality multi-professional workforce to support improved outcomes for patients and service users.

Evidence-based practice is very important and an evidence base requires research. Money must be available for multi-professional research as well as just for the medical side.

Finally, I thank the Government for the announcement made by the Secretary of State that there would be a chief nursing officer on the national Commissioning Board and a director of nursing at the Department of Health. However, I would like those two posts and the nursing post at CCG-level to be written into the Act, because the nursing and midwifery professions are currently not enjoying the confidence of the public in many places and are asking the same question as was asked by Florence Nightingale on entering hospitals in the Crimea—who’s in charge?

The recognition of authority and accountability is important at service delivery level, as it is at the national board level. Very often, moral parameters get in the way and it becomes blurred. Eighty per cent of care delivered to patients is by nurses, and it is important to the public and patients, as well as the professions, that their leaders are recognised alongside other heads of professions and have equal voice at the table, with direct accountability to the chief executive or designated lead officer.

I therefore ask the Government to consider making the posts mandatory at national and CCG level. I am aware that the Government do not wish to be prescriptive, but that is necessary at this time to give reassurance to the professions, patients and the public that there is at least recognition of the position of nursing within the NHS. It is then up to the professions to ensure that they are worthy of recognition by delivering high quality, compassionate care.