Health and Social Care Bill

Baroness Emerton Excerpts

Wednesday 9th November 2011 Lords Chamber

[Baroness Morgan of Drefelin]

My Lords, I was delighted to lend my name in support of these amendments. We have had a tremendous debate, which is a sign that the Committee stage of the Bill is starting to get down to business and focus on some of the nitty-gritty, now that we have moved on from some of the more extremely high-level principles about whether or not we should see Clauses 1 and 4 in the Bill.

I very much support the opening remarks of the noble Lord, Lord Willis. He is chair of the Association of Medical Research Charities. I declare an interest myself as chief executive of a medical research charity, Breast Cancer Campaign. We are members of the noble Lord’s association, and are very grateful to him for the leadership that he gives.

There are very few points I want to add to the debate, as it has already been very comprehensive. In thinking about this, I want to stress how incredibly important it is that we understand the role of research in the NHS as a driver for quality and improving outcomes for patients. Only today at the AMRC AGM, I heard someone describing research as one of the three pillars, alongside service delivery and education, and stressing the role that research plays in driving up quality and outcomes for patients.

We know that this is something that is not lost on the public. We have already heard what importance the public place on research delivery in the NHS—93 per cent of people asked by the AMRC in a MORI poll said that they wanted their local NHS to be encouraged or required to deliver research locally. That is an enormous vote of confidence in research in the NHS.

The public do not just say this in answer to surveys. They vote for research through their wallets, as we have already heard from a number of noble Lords. Medical research charities contribute £1 billion to research in this country. That is an enormous achievement.

The contribution that the NHS makes to medical research worldwide is very special indeed. It is quite simply a no-brainer that research has consistently delivered real progress for patients. I believe it is agreed that the NHS has a special and unique role to play, which is unparalleled in the world. We have already agreed around the House that in this country we punch above our weight, as the noble Lord, Lord Walton, said. As the noble Lord, Lord Turnberg, said very eloquently, we know that the UK generates over 10 per cent of the world’s clinical science and health research outputs and has created nearly a quarter of the world’s top 100 medicines. That is a great achievement. Now that the noble Lord, Lord Darzi, is back in his place, I can remind the House that in the earlier debate he commented on how life expectancy continues to rise, following on from the success of medical research.

As I said at Second Reading, there are many examples where the special nature of the NHS has contributed to progress. I mentioned particularly the million women study, supported by Cancer Research UK in partnership with the NHS, a collaboration that revealed the role of hormone replacement therapy in breast cancer risk—an enormous study, made possible by the NHS. I also talked about a project that my own charity is involved in. It is a real challenge. Noble Lords have already made many points about the difficulty in establishing informatics systems. We are working to establish a tissue bank, to look at breast cancer specifically, and to drive forward the vital role that genomics plays. This is also made possible by the NHS. There are many examples, as I have said.

I welcome this duty. It is the first time we have seen a duty of this nature on the Secretary of State, and it is a very important step forward, but if the duty is going to be meaningful we need to know—so I would like to hear from the Minister—what the Government will see as success in executing that duty. I want to understand what success will look like—what will be the benchmarks that the Secretary of State will use to know whether his duty has been executed successfully.

Will we continue to evaluate the contribution that NHS research makes to GDP? How will the NHS research duty play in to the research assessment exercise that is undertaken in higher education? Could that be used to show how effective partnerships work in the NHS, because it is often those partnerships between NHS trust and academic institutions which are so important? What could Monitor or the Care Quality Commission do to help us understand the contribution that research has made to improving outcomes in various settings? Will we have an impact rating for NHS foundation trusts relating to their promotion of R&D? Will we be considering the number of patients in clinical trials as a measure—that is something that many people are worried about at the moment? Should we be looking at the number of clinical fellows or clinical professors in surgery?

What will success look like for the Secretary of State? I have heard talk that a research tariff is being developed; that has been referred to in correspondence. I would be grateful if the noble Earl could explain whether it is and what the consultation process might be. There has been a suggestion that a diagram or an organigram might help us here when looking at how the funding streams might work. We had a meeting with Dame Sally Davies when that was on the agenda. We have been reassured that funding will work in the same way as in the past. I am not sure whether it can, so I should be grateful if the Minister could reassure us on how that would work and perhaps produce a diagram for us.

[Baroness Emerton]

My Lords, I have appreciated all the contributions on the amendments on research. There is just one thing that I take issue with: the contribution of the noble Lord, Lord Ribeiro, who said that his profession was the Cinderella of research. Other professions would describe themselves as being Cinderellas in terms of research funding. Obviously, I speak for nursing and midwifery, but also for the other healthcare professions, which are all graduate professions and which are concerned to give evidence-based practice wherever they are in the NHS. Perhaps the noble Earl could re-emphasise that it will be multiprofessional research. All the contributions this evening have been on medicine and scientific research, but the other professions can contribute an enormous amount. Nursing is very reliant on charitable, voluntary funds for its research and has done some tremendous research exercises in clinical procedures, as have the other professions—midwives and physiotherapists. Will the noble Earl consider this being a multiprofessional research board?

[Lord Darzi of Denham]

My Lords, I add my support to Amendment 42. I declare an obvious conflict: I am a recipient of funding from the National Institute of Health Research; I am also a senior fellow in the NIHR.

We should all be very proud that huge investment has gone into research in the NHS. The reforms of the past decade have been significant. We have been used as the exemplar across the globe not just on funding but on the structure and the processes, driving research within the NHS.

I should like to cover not just the health gains but the economic gains of research. Whichever way we look at it, the life science industry is worth about 4.3 per cent of our GDP. That is a significant contribution. The life science industry employs between 170,000 and 180,000 people. We are still very attractive to the pharmaceutical companies, which come here because some of the best brains are coming out of our universities. We need to work on making the NHS as attractive as the university sector. That is why safeguarding of funding within the National Institute of Health Research is vital for that important mission if we are to contribute to future economic growth.

Health and Social Care Bill

Baroness Emerton Excerpts

Tuesday 25th October 2011 Lords Chamber

[Lord Warner]

I ought to make clear that I was not launching an attack on the noble Lord, Lord Ribeiro, with whom I had an excellent relationship as a Minister when he was president of the Royal College of Surgeons.

I finish by saying that although we are making progress on this Bill by having amendments of this kind early on, it is important to realise their limitations. A number of noble Lords, particularly my noble friend Lord Turnberg, have raised a whole raft of issues which still need to be grappled with. This may be the first of a number of debates we have on the issue of education and training as we try to strengthen the Bill in this area.

[Baroness Emerton]

My Lords, I rise as the one nurse here. The debate so far is music to my ears but it would be even more so to the professions. When the Bill was published there was great concern and great disappointment that we had to wait for education and training to come as a further step in the White Paper and after this Bill. They see, as I think every professional here sees, that education and training is a fundamental basis for ensuring the primacy of patients.

This Bill gives an opportunity to look at the future of health and social care and to bring in integration and holistic care, as was pointed out at Second Reading. To do that, we have to look at the education and training of all healthcare professionals, and the holistic approach from primary to secondary and tertiary, back to primary and community care, and to work alongside social care.

One of the things that we particularly need to address is the commissioning of the workforce in the future. The noble Lord, Lord Warner, has mentioned the strategic health authorities. I am sure that we all have comments against the strategic health authorities, but one of their functions was to engage in workforce planning. At the moment, it does not seem at all clear how the commissioning will be for the future workforce of healthcare professionals. This will be a great issue that needs to be addressed urgently because we all know that education and training is a three or four-year process—longer for doctors. It will need to be addressed immediately.

I want to support the amendment tabled by my noble friends Lord Walton and Lord Patel, proposing an overarching responsibility for the Secretary of State. I am sure that we will have certain other amendments, which have been already mentioned, and future debate. I would just say how urgent it is that we get something in the Bill to reassure the professions that education and training are essential for the primacy of patients.

[Baroness Jolly]

My Lords, it seems that we are now getting an outbreak of agreement that there should be a duty on the Secretary of State regarding education and training in the Bill. This is to be welcomed.

The noble Lords, Lord Mawhinney and Lord Kakkar, put it really well, and I will slightly paraphrase what they said. The delivery of high-quality patient care is absolutely predicated on quality training. It is also critical, however, that standards are set, maintained and monitored, not only for doctors and nurses—we have heard a lot today from very eminent doctors—but for allied health professionals.

There will, however, be a plethora of local healthcare providers: some within the NHS and some outside. We are anxious to ensure that the local responses to the delivery of training will meet these standards. We hope that proper checks and balances will be put in place to give some sort of national oversight on this. The noble Baroness, Lady Finlay, alluded to this in her remarks. I was going to carry on by giving a couple of examples about the need for co-ordination across providers and talking about these independent treatment centres. I will refer only to phase 1 and not to phase 2; we will have got it right by then.

There were complaints, certainly in my local district general hospital, that doctors were seeing only quite complicated operations and not standard ones. It was to do with hips there, and we have already heard about elbows or shoulders elsewhere. Similarly, the noble Lord, Lord Winston, cited hernias and I have a hernia example, which I shall not share with the House.

With this Bill, there is a wholesale need for a total change of culture within the NHS about the way we work. If we put patients at the centre it will create a huge need for training. It will be one-off training in the first instance but it will also need to be ongoing. This is something that I had hoped the Future Forum might be considering as part of its deliberation.

We are assured that the Government are keeping deaneries in place at present, but we share the anxiety of some of the royal colleges about their future. I have to repeat what others have said—and I heard it only this morning: there really is anxiety about this second Bill. The first assurance was that it would come in the next Session but now organisations are worried that the delay might be even longer. Therefore, we need something from the Minister that will help to focus people’s attention and give them confidence that things are in place.

I have spoken to universities and other providers of training. They need reassurance and certainty, too. They need to plan their staffing and, in this, they form part of the health economy. It is in no one’s interest to destabilise them. Can the Minister offer such reassurance on this?

We welcome the duty for Monitor to have regard to the need for high standards in the education and training of healthcare professionals. How will this interact with the potential for insufficient caseloads, in some circumstances, to train new healthcare professionals properly? How will national oversight of education and training be carried out to ensure higher quality? All these areas need to be teased out further, and we will come back to them on Report.

We all acknowledge the critical need for training and for standard setting. Can my noble friend give the House some reassurance that he will look at these issues again and, where possible and appropriate, consider regulation as a way of moving some of them forward in advance of the Bill?

Nursing: Elderly and Vulnerable Patients

Baroness Emerton Excerpts

Wednesday 19th October 2011 Lords Chamber

[Earl Howe]

My noble friend is quite right and there is now a renewed emphasis on that very point, with initiatives to help the nursing workforce practise to the highest clinical standards. These include Essence of Care, which outlines quality provision of the fundamentals of care, and Confidence in Caring, which improves nurse interaction with patients. While national initiatives such as those can stimulate thinking and offer guidance on best practice, it is really the local nurse leaders, team leaders, ward sisters and matrons who are key to setting and maintaining standards for quality and safety in their own clinical areas.

[Baroness Emerton]

My Lords, state enrolled nurses’ training was discontinued on the mere fact that those nurses were being abused and misused, because they were being asked to do tasks that were above the level of their competence. We are in the same situation now with these healthcare support workers, who are not trained to a level where they can accept the tasks being delegated to them. I ask the Government to look at this, because we cannot continue to misuse those support workers in the way in which we are—by their being given tasks which they are not suited to.

[Earl Howe]

The noble Baroness, with her expertise, makes a powerful point. We fully agree that there is an issue over unregistered healthcare assistants; I think the debate is around what we should do about it. We believe that the case for statutory regulation has not been made, although we would not close our minds to it. The point that the noble Baroness makes relates much more to nursing supervision, appropriate levels of delegation on a ward or in a care home, and appropriate supervision and training. That is a matter not for regulation but for nurse leaders in hospitals and care homes.

NHS: Standards of Care and Commissioning

Baroness Emerton Excerpts

Thursday 31st March 2011 Lords Chamber

[Baroness Emerton]

I thank the noble Lord, Lord Turnberg, for raising this timely debate. Without doubt, corrective action is required to deal with these issues. They will not go away unless that happens. This fact is reflected in the 57 per cent increase on last year in referrals from the general public to the Nursing and Midwifery Council fitness to practice committee in the months of January and February this year. The total was 833—a dramatic increase.

On 3 March, I asked when the Government were going to respond to the report of the Prime Minister’s commission on nursing and midwifery, published in March 2010. I declare an interest: I am proud to say that I am a nurse and that I was on the commission. The Minister replied that he would check where the Government were on the formal reply. I raise this again as no response has been received and because a year was spent by 20 senior and distinguished nurses, midwives and health visitors looking at the problems that faced us.

Evidence was collected following meetings with the public, stakeholders and students, and left the commissioners in no doubt that a “care quake” was approaching—driven by healthcare trends, social changes, demographic changes, families outsourcing care, growing numbers of people with long-term conditions and the additional complex conditions resulting from the ageing process. The nursing professions are centre-stage to handle the care quake, but must be properly equipped and supplied to deliver truly compassionate care that is skilled, competent, values-based and that respects patients' dignity with clear, respectful communication to patients and relatives.

We gathered from extensive engagements with the public that they felt strongly that the public image of the nursing, midwifery and health-visiting professions is out of date and that a new story of nursing is needed. The clearest message was that the traditional image of the front-line sister or leader of a community nursing service should be restored to the former point of visible authority and clear leadership role, answering the cry, “Who is in charge?”, at front-line level.

The commissioners set to work to make recommendations for the largest single workforce in Europe. There are currently in excess of 625,000 nurses on the register. The NHS nursing and midwifery pay bill is £12 billion, with more than £l billion spent on pre-registration nursing and midwifery education. There is little research on the cost-effectiveness and cost-benefit of nursing-led services, and existing research is often ignored. A recent scoping review commissioned by the Nursing and Midwifery Council found that there were 300,000 healthcare support workers in the NHS that were unregistered, posing a potential risk to patient safety. Recently the Mid Staffordshire complaints officer stated in evidence to a public inquiry that the ratio of trained nurses to support workers had swung to 40 per cent trained and 60 per cent healthcare assistants over the period 2002 to 2009. That was a change to address the £10 million overspend in the trust.

The move to make nursing a degree-level profession by 2013 is an integral step in ensuring that registered nurses and midwives have an academic base to translate into high-level, quality compassionate care.

Of the nursing commission’s 20 recommendations, I wish briefly to highlight four. The commission said that the nursing, midwifery and health-visiting professions should deliver high-quality care and that leaders should accept full managerial and professional accountability for ensuring that the organisation provides high-quality, compassionate care. The boards should ensure that care champions strengthen the front-line managers—for example, sisters and charge nurses. There was a call for advanced practitioners and healthcare support workers to be regulated, protecting the title “nurse” and limiting its use to those on the NMC register. This would be equivalent to “enrolled nurse”, as has already been mentioned. Another recommendation was that nurses and midwives should contribute to health and well-being, reducing health inequalities.

I hope that Her Majesty’s Government will respond quickly and positively to the commission’s recommendations, which all go towards achieving an improved nursing profession that will meet the needs of the community with compassion and with respect for the elderly.

[Baroness Northover]

My Lords, perhaps I may remind noble Lords, as I did in the previous debate, that we have a very tight time limit in this debate. Therefore, when the Clock reaches “4”, noble Lords will have completed their allotted four minutes.

Health: Care and Compassion?

Baroness Emerton Excerpts

Thursday 3rd March 2011 Lords Chamber

[Earl Howe]

My Lords, I am sure the whole House will recognise the contribution that my noble friend has made to raising awareness of these very troubling issues, and I pay tribute to her. She is right, which is why our proposals for the NHS place a great deal of emphasis on strengthening accountability at every link in the chain, so that the complaints that she has referred to are dealt with speedily and someone is held accountable for what has happened.

[Baroness Emerton]

My Lords, will the Minister please say whether it is the Government’s intention to respond to the previous Prime Minister’s commission on nursing, which reported in March 2010? There were 21 commissioners, and I declare an interest as one of them. The report made 20 recommendations, 17 of which relate directly to the ombudsman’s report and, if implemented, would go some way to curing some of the types of incidents that were reported. There is a great need on the part of both the employers and the employees, and it was good to hear the Minister say that a letter has gone to the employers. Would it be possible to have an answer to the commission so that we could see the implementation of some of these recommendations? I am ashamed to be named a nurse when such dreadful care and lack of supervision have been identified. We have a responsibility here. I ask the Minister to look at the supervision of untrained staff and the regulation of assistant nurses.

NHS: Pain Management Services

Baroness Emerton Excerpts

Wednesday 7th July 2010 Lords Chamber

[Baroness Emerton]

My Lords, I wish to add my thanks to my noble friend Lord Luce for initiating this short debate, following up his previous attempts to improve the multi-disciplinary approach to managing chronic pain. I declare an interest as a retired nurse and fully support multi-professional involvement. I certainly agree with the noble Baroness, Lady Pitkeathley, about the importance of care, compassion and communication as vital accompaniments. I also support my noble friend Lord Luce in urging the introduction of the fifth vital sign. It is extremely important that that is implemented.

There also appears to be a hold-up in extending the prescribing role of nurse consultants to patients suffering from chronic pain, although they are able to prescribe opiates to those suffering from acute pain or if they hold the role as a palliative care nurse. However, in a chronic pain clinic they have to refer the patient back to the GP. I understand that this causes great frustration to the patient, the GP and the nurse, and is wasteful of resources. I urge the Minister to look into this, please, to see whether it can be untangled.

I wish also to draw the Minister’s attention to an aspect of chronic pain that is preventable and very cost-effective. Reference has already been made to Dame Carol Black’s 2008 report, Working for a Healthier Tomorrow, which found that early intervention enables staff to return to work quickly, particularly where illness has the potential to become chronic and long-lasting, such as in the musculoskeletal disorders. Her report found that for employees with lower back pain, early intervention sees them return to work up to five weeks earlier than under normal care and reduces the recurrence of back pain in the following year by up to 40 per cent.

The Secretary for State for Health has made much of the need for an NHS that is focused on prevention and wider public health. Taking measures to safeguard nurses from back pain could be a tangible commitment to this. According to the Boorman review of November 2009, NHS Health and Wellbeing, which was acknowledged by the former Government, sickness among NHS staff in England currently accounts for 10.7 million lost work days at a cost of £1.7 billion. Some 30 per cent of the staff of the NHS are nurses. A national audit into clinical back pain management found that nurses and nurse support staff were more frequently absent than any other healthcare professionals with back pain caused by the level of manual handling in their jobs. It is not clear what the exact cost of back pain related nurse illness is to the NHS, but as nurses comprise the largest part of the workforce, it must make a significant contribution to the costs highlighted by Boorman. In addition, professional compensation awards can be significant. In recent years, awards of £800,000 and £400,000 have been made for work-related injuries. Early intervention to prevent nurse back pain related illness could help prevent a genuine risk to patient safety.

In the interests of ensuring patient safety, saving large sums of money as a result of preventive action and producing a healthier workforce, will the Minister add to the requests of other noble Lords my request for government action to encourage regular risk assessments, training in updated manual handling procedures and the supply of adequate equipment, especially in the community services, as well as a recognition of the need for early intervention in signs of lower back pain in nurses, support workers and other healthcare professionals? There is a saying that prevention is better than cure. Focus on prevention in this field would be of great benefit to patients, staff, management and the economy generally.

Health: Primary and Community Care

Baroness Emerton Excerpts

Thursday 24th June 2010 Lords Chamber

[Baroness Emerton]

My Lords, I, too, warmly congratulate my noble friend Lord Mawson on, first, introducing the debate but, more importantly, on demonstrating through his entrepreneurial approach what has been achieved in managing change of this magnitude in what at first sight must have seemed an impossible task.

We have had put before us lessons taught in managing change through people to provide a community service in every sense of the word. Like many other noble Lords, I found my visit to Bromley by Bow Centre a manifestation of real entrepreneurial skill— second to none in demonstrating holistic care in the most imaginative ways—which became not only productive in outcome but engaged the patients and community members in a non-conventional way. The emergence of a true community was evident. I found my noble friend’s book very gripping, for no punches were spared in the description of both the barriers and the successes.

I declare an interest as a retired nurse. Over the past 10 years, much progress has been made in community services to encompass a wide range of services, including public health and prevention services, but despite many primary care and community initiatives we still have a long way to go on early identification of disease, risk factors, reduction of health inequalities and the promotion of child health. In the development of urgent care, acute care at home and end of life care services, community services work in close partnership with the GPs, hospital services and social services to support the independent living of older people and the safeguarding of vulnerable adults. They also work with children’s trust partnerships. Currently, 200,000 staff are employed to meet these services, requiring £10 billion from the NHS budget. There is considerable evidence of widespread variation in productivity, which, if addressed, could generate a substantial direct improvement in service quality and sustainable efficiency, thereby reducing costs.

During the past 10 years, attempts had been made by the previous Administration to improve services through the recommendations in the NHS Plan, published in 2001, the general medical contracts in 2004, and the White Papers, Our Health, Our Care, Our Say in 2006 and Transforming Community Services, published last year. The Nursing and Midwifery Council, its regulator and its predecessor, the UKCC—of which I declare an interest as a former chair—have long supported the provision of healthcare in the community. During the previous decade, they introduced specialist community practice awards and created a specialist community health nursing part of the register. These measures acknowledged the shift in expertise needed to ensure safe community practice. While not yet enforced, the emerging standards for pre-nurse education will require pre-registration students to spend 50 per cent of training in practice-based settings, which will increasingly be within the community as services are reconfigured. This represents a sea change in nurse education and will herald a major improvement in healthcare delivery at the point of registration. The planned 4,200 increase in the number of health visitors is admirable. They play an important cross-professional, co-ordinating role, leading skill mix teams in delivery, postnatal, early-years and family healthcare.

However, it is important that health visitors retain a grounding in basic nursing and/or midwifery skills. Knowledge of diabetes, associated obesity, childhood ailments, immunisation, prescribing and disease management are all essential to ensuring safe delivery of patient care pathways. The Nursing and Midwifery Council is looking for the best way to take forward the preparation of health visitors. Will the Government support this initiative?

The introduction of matrons, advanced practitioners, specialist nurses and consultant nurses in the community has resulted in many patients with complex, long-term conditions being expertly cared for without the need to frequent their local hospital. Community matrons in particular are striving to help people with long-term conditions become more self-reliant and better informed about their health and how to improve it. This reflects a shift in emphasis towards nurses helping to empower patients to look after themselves and manage their conditions better.

The programme to support practitioners to transform services and deliver high- quality care and productivity set out evidence for best-practice care within community services through a series of six transformational reference guides entitled, Health, Well-Being and Reducing Inequalities; Services for Children, Young People and Families; Acute Care Nearer to Home; People with Long-Term Conditions; Rehabilitation Services and End of Life Care. All of them provide a guide to high-impact changes and are intended to enable practitioners to give high-quality care.

The continuing work is looking particularly at the needs of frail, elderly patients with complex health conditions. They are the main service users of community healthcare and now occupy the majority of acute hospital beds. Increasing evidence points towards a wide variation in the care offered to the elderly. Studies indicate that up to 30 per cent of people in hospital at any one time, many of them frail and elderly, could be safely cared for in the community with the right access to community services and appropriate support. There are efforts to mobilise staff using evidence to create a “social movement” among front-line staff and empowering clinicians to lead change and innovation. This leads to the use of care pathways to increase care co-ordination and best practice for patients. Combining primary, community, hospital and social care to increase efficiency and provide high-quality care, it is best described as “care without walls”.

At present, a high proportion of residential nursing homes employ healthcare support workers and social care workers. Evidence from a study conducted by Ian Kessler at Oxford University shows that many undertake aspects of care traditionally done by nurses but that they are not trained to do it safely. If there is to be an increase in community care, increasing the level of social carers and healthcare support workers, there must be an increase in safeguards on the roles undertaken by those staff. With no form of regulation in place, it is difficult to track and prevent those unable to provide safe levels of care. The move to community-based care poses a significant risk to patient safety.

Against a background of the demographic growth of the elderly population—requiring an increase in both long-term and acute home care—of the care of vulnerable children in pre- and post-natal care and of changes in the pattern of commissioning services, it will be important to ensure that at every level a nursing voice will be able to ensure the safety of patients as well as the delivery of high-quality care in the most cost-effective way. It is imperative that the new systems of commissioning primary and community services enable the voice of an experienced nurse to ensure that the resources and training facilities in clinical placements are sufficient to meet the need.

The Royal College of Nursing continues to express its concern over the lack of investment made into the community nursing workforce. A particular concern is the problem of the ageing nursing workforce, as 27 per cent of nurses working in community services within the UK are aged over 50. Over the next 10 years around 180,000 nurses will be eligible for retirement, leaving a huge hole in the workforce which, at current levels of commissioning, will not be met by future recruits. There are concerns that the problem will be magnified through the current period of financial constraints by recruitment freezes and the deletion of posts as a result of efficiency savings. There has also been evidence of an active reduction in student places being commissioned, despite a record number of applications to enter the nursing profession. This, it says, is a great disappointment and a blow to all that has been done to improve the attractiveness of nursing as a career.

The leadership skills required are of paramount importance and it is through people rather than policies that change can be effected. The challenges of overcoming the barriers between various services are enormous but the opportunity to grow community services must not be lost. Just as my noble friend mentioned, it takes time to break through the barriers and that cannot be rushed. Certainly, in my experience of leading and managing a project relocating 1,500 and then a further 1,200 learning disability patients from two large hospitals, it took 10 years to ensure that every patient was individually assessed, relocated according to their needs and placed into the most appropriate accommodation. That involved seven London boroughs and two county councils—none of which was keen to take back its residents—while ensuring that staff were appropriately trained to care for residents in the community, which was completely different from being within the large hospital and a big culture change for them. There were relatives reluctant about their relatives transferring from the safe environment provided by the large hospital to an open community and there was the receiving communities’ reluctance to receive learning disability clients.

While there was an overall strategy accompanied by a critical path analysis setting target dates, that project really required hours of careful negotiation through the barriers to result in a changed culture—one providing a more meaningful style of life for clients in a safe environment, while delivering high-quality care and management. Managing such an innovative project, as with those that we have heard described this afternoon, was certainly a huge learning curve for me—and, I am sure, for others. I believe that there is an urgent need for nurses and all healthcare professionals to gain the necessary leadership skills to be equipped to meet the challenges and opportunities of the future’s reconfigured community services.

First Aid

Baroness Emerton Excerpts

Thursday 17th June 2010 Lords Chamber

[Earl Howe]

My Lords, my noble friend is absolutely right. The kind of basic first aid provided by community first responders, as they are called, is extremely important, not least in terms of operating defibrillators. However, that sort of service should be seen as complementary to and supportive of ambulance responses to emergencies. It is not a substitute for emergency ambulance response, and it is right that my noble friend should raise that distinction.

[Baroness Emerton]

I declare an interest as a former chief commander of St John. I am in touch with the recent campaign. It is interesting to note that there were 250,000 responses to an advertisement from people showing an interest in first aid, of which 70,000 indicated a desire to learn more about it. As part of this campaign, St John has decided that it needs to concentrate—the noble Lord, Lord Harrison, has already mentioned this—on young people and the workplace. An interesting statistic is that 45 per cent of incidents where resuscitation is required occur in offices rather than on building sites. Will the Minister assist St John and the many other agencies by supporting their call to improve workplace facilities for first aid to take place?

[Earl Howe]

My Lords, the noble Baroness makes an important point. We all know that St John is active in major emergencies and road accidents and was active in the London bombings of five years ago. She is absolutely right that accidents in the workplace are a significant feature of the kinds of injuries that hospitals see. The ambulance service extends training in the workplace in a number of areas. However, I shall go back to the department and inquire about the extent to which St John in particular is doing this work. We may be able to feed in some important messages.

Queen's Speech

Baroness Emerton Excerpts

Thursday 3rd June 2010 Lords Chamber

[Baroness Emerton]

My Lords, I, too, welcome the noble Earl, Lord Howe, to the government Front Bench and offer him my congratulations on his appointment as Minister for Health. I am sure that his experience, knowledge and wisdom will be invaluable in taking forward the five priorities set out by the Secretary of State for Health and the long list of proposals within the health section of the coalition programme for Government. I also congratulate the noble Lord, Lord Hill, on his appointment and his mastery of the subject in his opening and maiden speech. I welcome my noble friend Lord Kakkar to the Cross Benches and congratulate him on his maiden speech. I am sure that his expertise in the area of medicine will be of great benefit to the deliberations of this House.

As I read the coalition Government priorities in the health section, I could not resist casting my mind back to 1953 when I started as a student nurse. At that time the ward sister reigned supreme and the matron was to be obeyed not only by the nurses but also by doctors and administrators alike. In my time, I have experienced six major reorganisations of the NHS, all of which had good points. I agree with my noble friend Lady Murphy that changes of organisational structures are sometimes good, but there are also things which are not so good. The one that stands out and disappoints me is the lessening of authority and accountability of the ward sister and the community sisters through to the director of nursing, both in hospitals and in the community. Therefore, I am delighted to read that:

“We will stop the top-down reorganisations of the NHS that have got in the way of patient care. We are committed to reducing duplication and the resources spent on administration … We will cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the front line … Doctors and nurses need to be able to use their professional judgment about what is right for patients, and we will support this by giving front-line staff more control on the working environment”.

It important for us to note that professional judgment and working with more autonomy and higher levels of the critical thinking and problem-solving skills are core elements at the heart of the Nursing and Midwifery Council’s review for pre-registration education and the move to the degree, under which the Nursing and Midwifery Council register will from 2013 require all registrants to have a degree. All those standards have a clear synergy with the Government's vision of the role of the future professionals in the NHS. The proposals all echo the recent recommendations of the Burdett Trust for Nursing in Leadership and the Business of Caring, the RCN’s recent work on strengthening the role of the ward sister and the most recent recommendations of the Commission on the Future of Nursing and Midwifery Professions.

I very much hope that the coalition Government will grasp this opportunity to develop and enact those policy statements with the benefit of improving the quality of patient and client care; ensuring that there are clear lines of accountability and authority well-defined and understood from the patient, the client and the public level through to the board level, including enhancing the role of the nursing voice at board level; and being knowledgeable of the wider context of the NHS, conversant with modern nursing practice and measuring clinical outcomes both in hospital and in the community.

It is also important to note that the announced cuts in finance will not exempt the multi-professional education and training budgets and that the current £4.8 billion will be reduced by 10 per cent, most affecting undergraduate and postgraduate education in medicine and dentistry. The £0.8 billion which is used for continuous professional education and national innovations is the most vulnerable. That raises concerns about the Government's ambition to raise quality of care standards and the future shape of the workforce. Balancing the necessary cuts to meet the overall deficits will require the highest quality of medical and nursing professional management skills to ensure a workforce that will protect the safety and well-being of patients, together with the priority to raise the profile of public health, which will require knowledge and expertise so that clinical outcomes of patient experience and safety are met, as well as meaningful health promotion and prevention of disease being developed further.

I refer to two other important issues. The Government have said that they will seek to stop foreign health professionals working in the NHS unless they pass robust language and competency tests—a crucial policy requiring action to change the current interpretation of the EU legislation, the professional qualification directive 2005/36. This prevents regulators from assessing the language competence of EEA professionals before admitting them to the registers. Currently, assessment is left to employers, not the regulators, and ignores the fact that many health and social care professionals are independent practitioners who practise outside the NHS and formal management assessments. The Nursing and Midwifery Council exists to safeguard the health and well-being of the public, and all nurses and midwives on the register should be safe and effective in practice, but the regulator is not permitted systematically to language-test trained applicants, therefore undermining the integrity of the register and presenting a risk to the public. The situation is also confusing to employers, applicants and the public, leading to a potential risk to the health and well-being of the public.

I ask the noble Earl to ensure that the 2012 review of directive 2005/36/EC on the recognition of professional qualifications reflects these concerns. Health and social care professions from outside the UK make a significant contribution to healthcare in this country, but patient safety must always take priority over free movement of labour.

While I share the concern of my noble friend Lord Sutherland about the delay in the introduction of long-term care and the suggestion of a commission, I hope that the Government will quickly take forward the commission and bring forth a sustainable structure of funding for long-term care. The part played by nurses and social care workers will be crucial in establishing the three Ps: prevention, personal and partnership. I should like to add the three Cs: care, compassion and communication, which are all essential ingredients that the public are looking for, especially in the light of the recent inquiry about Mid Staffordshire that demonstrated so clearly unacceptable levels of care. It pointed to the need for a highly competent workforce, high levels of supervision and management within a culture conducive to demonstrating compassion and communication with the flexibility to cross boundaries from health to social service and other partners. There is no doubt that there is a formidable list of proposed policies and I wish the Government well in taking them forward.