NHS Mandate

Baroness Emerton Excerpts

Thursday 25th April 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

The noble Baroness raises a very important point. This, of course, will not be part of the accountability framework but it is a very important question of concern for Higher Education England and the workforce strategy which is going forward. It has been a question of close discussion and debate between the Department of Health and Social Care and the Home Office and will continue to be so.

[Baroness Emerton (CB)]

The 2014 Act stated clearly that we were looking for safe staffing. The cry at the moment is an urgent plea for a safe staffing formula that will satisfy the needs of the whole population. As far as I can see, five years after the law was passed, we are now looking at another two or three years. We are really in a situation in which safe staffing is the top priority.

[Baroness Blackwood of North Oxford]

I thank the noble Baroness for her question. As I have said, the Government set out six principles underpinning the long-term plan to meet the expectations that the NHS has for the future. One of those principles is to ensure that the NHS is building the workforce that we need for the future, so that we have the right numbers and the right types of doctors, nurses and other expert professionals, with more of them being trained here in the UK. As part of the spending review period, we will be working to understand how we can get the funding necessary to recruit and train new staff as part of the HEE process for the workforce strategy.

NHS: Staff

Baroness Emerton Excerpts

Tuesday 13th November 2018 Lords Chamber

[Lord O'Shaughnessy]

I greatly respect my noble friend on this topic, which we have gone around several times. As he knows, I defend the current system as being the most progressive. Nevertheless, I am grateful for his report, which he sent me and which I am reading with interest. However, at this point, we are confident that we have the right policy.

[Baroness Emerton (CB)]

My Lords, how are the Government determining the safe level of staffing? In the Health and Social Care Act, one of the requirements was to look for safe levels. Could the Minister tell us how the Government will assure us that they are safe levels?

[Lord O'Shaughnessy]

I am grateful to the noble Baroness for that question. First, we have safe levels by recruiting more staff. We recognise that there is a need for it, and we are recruiting more staff in every category. The actual safe level of staffing is a trust-level issue that needs to be determined in response to the case load they have at any moment.

The NHS

Baroness Emerton Excerpts

Thursday 5th July 2018 Lords Chamber

[Baroness Emerton (CB)]

My Lords, I, too, congratulate the noble Lord, Lord Darzi, on opening the debate and thank him for being such a breath of fresh air, as he always is when he speaks in this House. I also thank the right reverend Prelate the Bishop of Carlisle for his words. It reminds me to confess my qualifications in the register as a retired nurse and midwife who started 65 years ago. I started in 1946 as a volunteer in the order of St John as a cadet, and learned the basics of life-saving and care. I have always been grateful for that background and the privilege that I had as a registered nurse.

In one of my jobs, as the youngest member of a consensus management team, I was asked to close two large hospitals and move mentally handicapped patients into the community. The first hospital had 1,500 patients and the second had 1,200 patients. It was my job to find a team that would work with me, with the money coming from the health service. I learned a tremendous amount about social services, working with two county councils and five London districts. It taught me one very large lesson: we have tremendous barriers that have to be broken down when we are concerned with delivering care. It is not a question of care in hospital and care in the community being different; we are looking at the whole person and their whole life. One thing I hoped, as I travelled through this task of 10 years, was that we were on the verge of reaching where we are today: considering bringing together health and social care.

I have always valued that experience, because I learned three things. One was that we needed the money, but that it needed to be spent cost-effectively and that we had to look at the way in which people were trained for this new model of care. The second was the high quality of care, which was different from that in an institution. The last was the culture in which people were cared for. I hope that, as a result of today’s debate and all that we have heard from the Government, we will be able to move forward, get rid of the barriers between health and social care and become one caring service.

The Long-term Sustainability of the NHS and Adult Social Care

Baroness Emerton Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Emerton (CB)]

My Lords, I thank the noble Lord, Lord Patel, and the committee members for the report. It was like taking a breath of fresh air when I read it. With my experience over some years in the health service, it came alive straightaway. The report states that the,

“biggest internal threat to the sustainability of the NHS”,

is the,

“absence of any comprehensive national long term strategy”,

to secure for the health and care system a workforce which is skilled, well trained and committed.

My personal experience started as a St John Ambulance cadet two years before the NHS started. It was drummed into me as a volunteer and a cadet that the most important thing was the safety of the patient. I joined the NHS as a nursing student in 1952 and worked in the NHS until 2000. Since then, I have done other work concerned with both, all of which is listed in the register.

I would like to take up the point about the workforce. First, every employee and volunteer has an important part to play in the delivery of care, and it is important that they understand their role. That was brought home to me very clearly when I was put in charge of laundries because I complained about the linen being unsatisfactory, with a high incidence of bed-sores. I think that I have related this story before but it is worth repeating. When I talked to the laundry workers, none of them realised that their job had an effect on the patients. My point is that every volunteer and every employee needs a clear job description and a clear understanding of their job, and they should be monitored to see that they understand the importance of patient safety.

Secondly, there is an issue not just in hospitals but in social care. Those with a mental handicap or learning disability and those with a mental illness have to be examined every six or 12 months by a panel to see whether their support allowance can be continued. The panel has set questions but no background information on what caused the injury or on why the money might be taken away. The relation of a personal friend of mine had a brain injury before birth but his allowance was withdrawn. He had a parent who lived some distance away and was living on his own. The point is that social care needs monetary support, and every person involved in it, as well as in the health service, needs knowledge of what the job is about.

Thirdly, the correlation of theory to practice within the professions is very important and we need to ensure that it works well. It was particularly important when producing graduate nursing courses that adequate clinical teaching was linked with educational supply. We need to see a closer relationship between educational provision and the delivery of care. Correlation of theory to practice is vital, and, again, that is important for volunteers as well.

My last point is that, in delivering care, workforce planning is not just a question of numbers. It must include an understanding of the occupations that are being looked at. We must see it as a job not just for administrators but for all aspects of the health service: clinicians, volunteer charities and the users of services must be involved. During the history of the NHS we have had attempts where this has been attained, but recently we have not seen workforce planning being spread across the services and understood by all the clinicians, as was mentioned this morning. This is so important for the future of health and social care.

In summary, my introduction to the NHS was at a time when the Second World War had just ended. There was a fear that medical care was going to be too expensive and worries about how everyone was going to manage. It was a tremendous relief to the population when the NHS was introduced by the Labour Government for the United Kingdom. That relief is being sought now by the public, who fear that health and social care services are in danger. I hope the Government will take on the recommendations from the report and we will see some action. I hope the Minister will be able to confirm that we will see movement, not just in the short term but for the long-term future, as has been mentioned.

My only adverse comment on the report is this. This morning, I was reminded that the Griffiths report mentioned Florence Nightingale looking for the missing nurse. There were no nurses on this panel.

NHS: Staff

Baroness Emerton Excerpts

Thursday 30th November 2017 Lords Chamber

[Baroness Emerton (CB)]

My Lords, I thank the noble Lord, Lord Clark, for his introduction. I declare my interests as listed in the register: I am a retired nurse and a retired midwife. I joined the health service in 1953 as a student nurse and I have had a privileged career.

I find it very sad to stand here and talk about the health service we see today. I have read the evidence given to the Health Committee in the Commons and all the up-to-date figures, and I find it extremely worrying and sad that, from a nursing point of view, we are faced with an unsafe situation. We spent four years on the Health and Social Care Bill and emerged with the phrases that the Government would look at safe staffing and the certification of untrained staff.

Fortunately, we have the services of the noble Lord, Lord Willis, who has taken up the cudgel for people who were untrained nurses, and a two-year programme for support workers, agreed by the Government, has been introduced. The question is whether, as nursing associates, they will be registered. The problem is that the NMC is the registering body for the four countries, and not all four countries are doing the same thing with untrained staff. We are in a situation where we have uncertainty.

The noble Baroness, Lady Walmsley, raised the question of a multi-professional, multi-Government approach. The health service has reached a crisis point where it needs a global or overseeing way forward. I am particularly interested because during the past year I have had personal experience of health and social care, both as a Member of this House and as a regional nurse. I have had experience of transferring patients from health into social care. We have enormous problems which need to be sorted through a multi-professional, properly funded and reassuring to the public strategy.

We cannot go on having statements. To step forward we need to deliver safe care through the patient pathway, from before life to the end of life. We may need to use volunteers in some aspects—which is very good if they are trained—but the public still expect a service they can trust.

At the moment, there is a situation where people are wondering whether they will get safe care, when they are discharged in the middle of the night to a home where there is no one. We need to see that there is a pathway for them right the way through. I ask the Minister that we take seriously all the information that has come in about shortage of staff—not just nurses but all across the NHS. There is a need to work together and break down barriers that are there. We need more multi-professional education where it would be cost effective. We have not built in cost-effective ways going forward in some instances. Anatomy is anatomy, so why do we do not have anatomy teaching where we have all disciplines coming together? There are all sorts of innovative points we could do.

So, as a disappointed, retired nurse—and retiring Peer in the near future—I ask the Minister that the health service is revived so that patients and the public can have confidence going to a surgery or whatever their need, so that they can be assured that their health will be cared for. I rest my case.

NHS and Social Care: Impact of Brexit

Baroness Emerton Excerpts

Thursday 21st July 2016 Lords Chamber

[Baroness Emerton (CB)]

My Lords, I congratulate and thank my noble friend Lady Watkins not only on securing this debate but on her excellent speech and setting the scene so ably this afternoon. I also thank the noble Viscount, Lord Bridgeman, for his tenacity of purpose. Ever since I joined the House, he has shown tenacity of purpose in regard to the English language and the statutory bodies.

I declare an interest as set out in the register. I am a retired registered nurse trying to keep up to date—and that is a job in itself. I will concentrate on the supply and delivery of quality care, not only in the National Health Service but in the private and charitable sectors.

In preparation for this debate, I gathered together the most recent headlines, which, I am afraid, do not make very happy reading. The Nursing Standard said:

“The United Kingdom is unprepared for nursing shortages”.

Health Service Journal stated:

“Reality bites as the NHS is told to face up to its failings”.

The BBC reports:

“Nurse shortage could last for years … 1 in 10 nurse posts in England unfilled … 29% of nurses are aged over 50 … 13% of nurses come from overseas”.

“Brexit may hit NHS nurse ‘pipeline’”,

says the chief executive of the NMC. The Nursing Times states:

“European nurses feel chill after Brexit vote”.

The Health Foundation report, Staffing Matters; Funding Counts refers to “pressure points” and associate nurses.

Like my noble friend Lady Watkins, I was filled with joy when I read the report from Simon Stevens. Like her, I had written my speech before I read his report. I will say more on that later.

I wish to take noble Lords back to the period before May 2010 when the Labour Government were in power and the noble Lord, Lord Darzi, the then Minister of Health, introduced care pathways and was seeking means of ensuring safe, high-quality delivery of care to the satisfaction of patients. Much progress was made on this but with the change of Government, the unmandated Health and Social Care Bill was introduced and proceeded through the next four years before completion. During those four years, I contributed at each stage of the Bill, along with other noble Lords, to establish safe staffing levels and either certification or regulation for support workers.

Since July 2014, much work has been attempted by various organisations to establish safe staffing levels comprising not just numbers but quality assurance by providing the appropriate level of competence of nurses and support workers. Without that assurance focused on the quality outcome, numbers alone will not take us forward. What we cannot afford is a further spate of inquires relating to unacceptable levels of low-quality care in view of the evidence of the dependency required by the patient, as occurred in the Mid Staffordshire inquiry.

The report by the noble Lord, Lord Carter, for example, relates to the number of workers and the number of hours per patient day required but gives no indication of the ratio of registered nurses and support workers. There is no regard to the spread. This presents a real dilemma: if the numbers required cannot be afforded as being both the right number with the right quality, then choices have to be made as to the level of service that can be provided, or alternative methods of funding have to be found. But what we cannot afford is further delays with the possibility of poor delivery of care because of the shortage of the right numbers of workers with the right qualifications in place. In short, we require a strategic plan that has explored options on numbers, quality outcomes, cost benefit, risk assessment and a timetable for implementation.

The regulation of support workers fell to Health Education England to initiate and the noble Lord, Lord Willis, produced the report Raising the Bar, which dealt with nursing associates. Work is now under way to pilot the introduction of the nursing associate and to build on the current support worker grade 2 and 3 to a level 4, extending the role to support the registered nurse, possibly with the academic requirement and aptitude to proceed to registered nurse training or to a degree.

While I applaud any possible move to develop further support for support workers and agree with the direction of travel, I find it difficult to accept the title “nursing associate”. This may sound pedantic but already there is confusion and many are referring in official documents to the “associate nurse”. The use of the word “nurse” is regulated by law, applying to those who have the required qualification and registration by the NMC. I am concerned that not only other professionals in the health service but—most of all—patients will be confused. To patients, quite rightly, a nurse is a qualified nurse. The fact that the person might not be a nurse at all would not enter their heads. If the title were, for example, “associate health carer”, it would indicate that they were not registered nurses but someone trained under the supervision of a registered nurse. This would help to prevent confusion—which could easily escalate—creeping into the title.

Evidence clearly shows that the previous state-enrolled nurses were abused and misused; they were exploited through being left in charge of wards with no appropriate support available. The likelihood of this happening must at all costs be eliminated. The advantage of the title “associate health carer” would be that the syllabus could include an introduction into social care aspects of the patient’s journey, which is especially necessary for care in the community, where we have the elderly, the mentally ill and some long-term dependent patients with learning disabilities who are cared for in the community but could be supported towards living a more independent life. This would provide excellent experience for those with the appropriate academic qualification. We need this opportunity for them to be trained and able to move forward, which would, we hope, break down some of the barriers between the organisations and the professions.

I suggest to the Minister that, while speed is of the essence to sort out the nursing associate, it would be preferable for health education to explore more fully the possible benefits that the role could have, for the benefit of not only the recipients of the care delivered but the nursing associate—or associate health carer—grade. The name is the key and it would be helpful if this could be examined. I look forward to hearing what the Minister has to say on that.

Safety and high-quality care cannot be ignored; we know the consequences of doing so are dire, as we witnessed in Mid Staffordshire, Winterbourne View and Southern Cross. We have to get rid of this idea of graduate nurses being “too posh to wash”. We urgently need to ensure the graduate nurses, on qualification, are responsible for the delivery of total assessment and care of the patient for whom they are responsible. Each patient is a unique individual who has a mind, body and spirit and it is the nurse who is responsible for assessing and addressing any issues that the patient may have, even if they are not immediately connected to the condition being treated. For example, a terminally ill patient may need to see a priest or the patient may be worried about a dependent relative who needs a social worker. The graduate nurse has the responsibility for the total holistic care of the patients allocated to him or her.

I also ask the Minister to address the question the noble Baroness, Lady Watkins, asked about the position of the nurse in the Department of Health. We are already in correspondence on this but it is a matter of great concern to the profession.

Learning Disabilities: Transforming Care

Baroness Emerton Excerpts

Thursday 9th June 2016 Lords Chamber

[Lord Prior of Brampton]

It is very clear in the NHS mandate that it knows exactly what it has to do. It was NHS England that produced Building the Right Support. There is a lot more governance around the programme now. Every month we will see the numbers of patients in in-patient care settings. The noble Lord will be interested to know that over the last year 185 people who had been in hospital for more than five years have now left hospital and gone into the community. There are signs that things are happening, but I would advise the noble Lord that what is needed is constant scrutiny.

[Baroness Emerton (CB)]

My Lords, I thank the Minister for reminding us how many patients have been removed from hospital, but I declare an interest that goes back to the 1970s, when I was responsible for transferring 1,500 and then another 1,200 patients from hospital through a joint working party involving social services and the health service. It seems that we have discharged patients. The Royal College of Nursing demonstrated in a recent report that, from the nursing point of view, never have so few nurses been trained in mental handicaps. People with learning disabilities have physical and mental requirements, as well as environmental ones. Safe staffing is the issue here. Following on from what the noble Lord, Lord Hunt, said, will the Minister please consider getting out an edict on the importance of looking not just at hospital staff but at community staff?

[Lord Prior of Brampton]

The noble Baroness raises a very important point. It is worth saying that an assurance board monitors the national transformation plan on a monthly basis and comprises local authorities as well as CCGs and others. On the workforce front, which is obviously crucial, it is no good putting money into a system if you do not have the right people to deliver the care. We expect the number of whole-time learning-difficulty nurses to increase from around 3,000 to more than 5,000 over the next five years, so there should be more resource going into this very important area.

National Health Service

Baroness Emerton Excerpts

Thursday 14th January 2016 Lords Chamber

[Baroness Emerton (CB)]

My Lords, it is my great privilege to welcome the noble Baroness, Lady Watkins of Tavistock, to the House and to extend warm congratulations to her on her most excellent maiden speech. It is an indication of the expertise that we can look forward to in her future contributions.

I thank the noble Lord, Lord Turnberg, for the opportunity to debate this important topic, which is to see how the NHS can be turned from a national sickness service back into a national health service. The rapid development of scientific knowledge, the growth of technology and research into the etiology of disease have led to valuable treatments for many conditions, and continue to do so, but at the same time the concentration on public health that was a priority at the inception of the NHS—preventing disease and promoting the health and well-being of the population—has decreased, although it remains a very important ingredient. Highly technical treatments and shorter hospitalisation now are appropriate but, because of the lack of community support, hospital beds become blocked.

As a retired nurse with 62 years’ experience, I am aware that the intent has always been to preserve the place of public health, but it has been overshadowed by the more exciting treatment side. The well-being of patients remains a requirement for nurses in the nurses’ code of conduct. A few lines refer to the fact that well-being in public health and care standards should be included in the syllabus of the nursing degree.

The NHS constitution also includes well-being as a responsibility of all staff. However, it is recognised within the Five Year Forward View that public health remains in urgent need of revival. That is for several reasons, the most important being the health of the population and the cost-effectiveness of a healthier population. Recently, Simon Stevens said that we cannot put more on the overstretched NHS staff. Healthcare professionals are the key to the future of the National Health Service. Unless they take a lead in promoting health and prevention of disease, nobody else will have the knowledge or the skills to take that forward. I do not refer just to doctors and nurses but to social services and all charitable contributors.

There is an in-built resistance to breaking down professional and organisational barriers but we must have the right leadership—leadership has been mentioned several times this morning—to take forward the health service so that it is not only a sickness service. It should be possible to influence and persuade lateral thinking and bring the holistic culture to health. It should start with the promotion of health, the prevention of disease, the treatment of disease and the well-being of the population, which should provide an evidence-based and cost-effective service.

The idea of the royal commission is good but, my goodness, a royal commission takes a long time. This is an urgent need and perhaps we may ask the Minister for a full debate on public health quickly.

National Health Service: Sustainability

Baroness Emerton Excerpts

Thursday 9th July 2015 Lords Chamber

[Baroness Emerton (CB)]

My Lords, I, too, congratulate my noble friend Lord Patel on securing this debate and on his timely contribution.

I refer back to the 1942 Beveridge report and the six years it took for the politicians to agree the NHS Bill and launch the NHS. I have been privileged to serve the NHS for 60 years, during which time many reports have been published proposing changes to meet the needs of the times.

I looked back to 1948—three years post-war—when ration books were still in use and young men were called up for national service. One thing was very apparent in 1948—the NHS would not have to deal with obesity. My thoughts wandered further and I wondered if the Minister might consider treating the national obesity problem by reintroducing rationing and national service—one way of improving the general health of the population, but I fear it would not be too popular.

Since the inception of the NHS, much progress has been made in diagnostics and the treatment of disease, alongside progress in the fields of medicine, nursing, midwifery and professions allied to medicine. There have been changes in the management of the services, usually heralded by the dreaded word “reorganisation”. Some of these have been for better, and some for worse. The nursing and midwifery professions have had their share of changes in regulation, education, practice and management; again, some for better, and some for worse. I believe the nursing and midwifery professions have in fact weathered the changes with positive outcomes. Nurses always rise to the occasion and many might describe them as unsung heroes or heroines because they always go the extra mile, not just because of the NHS constitution or their code of conduct, as important as those are, but because they really care about the delivery of care to patients. However, the two professions are generally poorly understood, as explained in the recently published book by Davina Allen, The Invisible Work of Nurses. She writes:

“There is a widely held view that all systems tend towards disorder and that energy is required to maintain order. Nurses are the source of this energy in healthcare. Formal organisations have a tendency to overestimate their orderliness and the degree to which their activities are governed by rational systems and processes. Yet in so far as healthcare exhibits any order, the findings of this study show, this must be understood as a nursing order”.

It is timely for me to pursue this a little further as there is a great risk, as Ministers and the Government make decisions quickly in order to deal with the current financial issues, in looking for quick ways to solve the problems. In the current situation, the role and complexity of the work of nurses and midwives is poorly understood, especially the role of the registered nurse. There is categorical evidence that degree-level education of nurses is associated with lower mortality rates in hospitals. Suggesting that another level of registered nurses might be the answer ignores all the previous research, which demonstrated that the state-enrolled nurse was “abused” and “misused”. This was to the detriment of safe care to patients and unfair to the enrolled nurses, who were placed in impossible positions, leading to many mistakes. The opportunity to develop further the roles of the current workforce would be more appropriate, in order that new models of care could be introduced to assist in developing new pathways of patient care—integrated care, for example. The support to the registered nurse is vital, as is the work currently being undertaken by the noble Lord, Lord Willis.

Planning the nursing and midwifery workforce in a time of national economic difficulty and ensuring the safety and delivery of high-quality care is not an easy task. But it is imperative that it is guided by a proven evidence base. If the outcome is unaffordable then difficult decisions have to be made as to the level of service that can be provided, or money found to meet the costs. These are hard decisions but it is better to be safe than sorry. Another Mid Staffordshire, Winterbourne View or Morecambe Bay cannot be afforded and it would be wrong to exploit the nursing and midwifery professions against an evidence base. The largest single workforce in the NHS cannot be expected to sacrifice its professionalism for a political expediency at a high risk to patients. The Chief Nursing Officer, who is leading this piece of work, needs the full support of the professions and the understanding of the politicians. Where would the NHS be without the seven-day service given by nurses and midwives now and in the future?

NHS: Immigration Rules

Baroness Emerton Excerpts

Wednesday 24th June 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Baroness makes a strong point. The drop-out rate of nurses is between 20% and 30%; it varies hugely from one nursing school to another. I am told that the peak of the drop-out rate is after their first clinical placement, which indicates that the way some nursing schools recruit their students is far from satisfactory. I hope that Health Education England will change the way it remunerates some nursing schools to ensure that they recruit the people with the right qualifications, temperament and vocation before they offer them places.

[Baroness Emerton (CB)]

My Lords, the Royal College of Nursing’s underlying concern in its report was the safety of patients due to shortage of nurses. The royal college is greatly concerned that there has been a cutback in training places because of the inclusion of overseas nurses over the last three years. Can the Minister see whether the report will result: first, in an increase of nurses in training back to the level of three years ago; and secondly, in revisiting the levels of safe staffing?

[Lord Prior of Brampton]

As usual, the noble Baroness is more than familiar with the latest developments in the world of nursing. Health Education England is committed to commissioning an additional 23,000 nurses over the next four years. On safer standards of nursing, I know that she has taken a keen interest in the work that has been done around nurse staffing levels in relation to the numbers of patients. It is the Government’s view that the actual decisions about safe staffing should be taken at a local level, based on the acuity of patients on the ward, and should largely be up to the judgment of the ward sister and senior nurses within the hospital.