Public Health England Advisory Board Membership

Baroness Jolly Excerpts

Thursday 4th July 2013 Lords Chamber

[Earl Howe]

My Lords, absolutely not. The noble Baroness to whom the noble Baroness refers is, in everybody’s eyes, a highly qualified person. It would be inappropriate in any case for me to comment on individual candidates, successful or unsuccessful. However, I can confirm, and I emphasise this strongly, that the recruitment campaign was managed in a way that completely complied with the principles of the Commissioner for Public Appointments’ code of practice. It was open and transparent, and appointments were made on merit against published criteria for the role.

[Baroness Jolly]

My Lords, will my noble friend explain what action is being taken to grow tomorrow’s female and minority leaders in health?

[Earl Howe]

My Lords, across the field of health it is difficult for me to give a generic answer, but the NHS Leadership Academy, which is now starting its work, will ensure that women with promise for leadership will be encouraged to come forward in a variety of roles, not just clinical but managerial. I hope that we will see the fruits of that work over the coming months.

Health: Diabetes

Baroness Jolly Excerpts

Wednesday 3rd July 2013 Lords Chamber

[Baroness Jolly]

My Lords, the House has heard that eye screening is critical for those with diabetes. As the national screening programmes are now commissioned by NHS England on behalf of Public Health England, and while diagnostic and treatment services are commissioned by clinical commissioning groups, will my noble friend tell the House what challenges these arrangements pose to the patient when trying to assess quality?

[Earl Howe]

The key thing here is for NHS England, Public Health England and local commissioners to work closely together, which is indeed what they are doing, so that the patient experiences a seamless service. Essentially, the new commissioning arrangements for national screening programmes enable effective commissioning and oversight of the whole screening pathway, alongside integrating those with the diagnostic and treatment services. To ensure a quality service, local programmes are assured by NHS screening programmes’ quality assurance teams and services are measured against 19 standards.

Care Bill [HL]

Baroness Jolly Excerpts

Wednesday 3rd July 2013 Lords Chamber

[Baroness Barker]

My Lords, I shall speak to Amendments 78A and 78B, which stand in my name and that of the noble Lord, Lord Hunt of Kings Heath. These and other amendments which will crop up throughout our discussions have been inspired by the Christian Science movement. I wish to say that I am not a Christian Scientist, but Christian Scientists hold to some very firm beliefs which are of great importance to them. Part of their belief system is that they do not wish to receive medical treatment in circumstances where other people would make a different decision. Therefore, in health Bills such as this, where we are setting out the principles that underlie what we define to be good care, it is not uncommon for me and the noble Lord, Lord Hunt, to put on record again that there is a spiritual dimension to health and well-being and that the way in which that spiritual belief is manifested can be different for minority groups.

One great strength of the Bill is that it takes a principled approach to what we define as well-being rather than attempting to define well-being in a descriptive sense. One reason why I think that that is increasingly important is that we have an increasingly diverse population. Therefore, the meaning of well-being for individuals is becoming distinct and diverse throughout society. The amendments place a duty on local authorities and relevant health bodies to respect the increasing diversity of our population.

There are two other reasons why I am very pleased to support the amendments. Like everyone else in the House, I am greatly in favour of the integration of health and social care. I see the undoubted benefits of that, but as someone who has worked in the field of social care, as opposed to health, all my life, I still carry with me the fear of the medicalisation of disability or of old age. When push comes to shove, when budgets are tight, some of the certainties which surround physical health, in particular, can overtake social goods which are less easy to define. Therefore, it is important that we ensure that we do not allow that to happen. One way to prevent that is by taking the approach of the amendments.

The final reason why I raise the amendments now is that I think that setting that out as they do right at the top of the Bill is a strong reminder to everyone who will refer to the Bill in years to come that the autonomy of individuals is an important part of health and well-being. You cannot have good health and be a fully functioning member of society if you do not have that autonomy, an autonomy which means that, in some cases, you have the right to make decisions which other people would regard to be unwise. It is a point of principle, but one which I think has a great deal of practical application not just for those who are receiving care but for those who are in charge of making decisions about it.

[Baroness Jolly]

My Lords, I am very sorry that the noble Lord, Lord Warner, is not in his seat. He tabled Amendment 79 to express the strength of feeling of Members of this House who were sitting on the scrutiny committee about the Secretary of State’s the duty to have regard to well-being. Were there room for more than four names to the amendment, there would have been more Members of your Lordships’ House on that list.

To put this in context—and the noble Lord, Lord Hunt, has taken us through quite a lot of this—this Bill was widely consulted. It was probably the coalition’s most widely consulted Bill; somebody might be able to tell me to the contrary. At each stage, people welcomed the well-being principle. Perhaps I may remind the House that in the majority report on the Bill, one of the recommendations was that the Secretary of State should have due regard. When the final Bill was produced, many in the sector approached me, and I suspect many others, to express their disappointment that that was not included in it. When the Secretary of State came to give evidence with the Minister for Care and Support, the right honourable Norman Lamb, he was very positive about it. According to the transcript of the session, Norman Lamb said:

“We absolutely want the wellbeing principle to apply comprehensively”.

The well-being principle is around the change of culture and it puts the person at the centre. It is absolutely critical that that happens, and next week we will debate the whole business of assessment and how we are undertaking it. However, unless the Secretary of State has to have regard to the same principle as local authorities, there is an opportunity for future Secretaries of State when making regulation to disregard well-being and just make regulation in the old way. One thing that sets this Bill aside from many others is that it is written in plain English and throughout its intention is pretty clear.

I ask the Minister if he is able to offer any assurance to the House, to the sector and to those for whom the Bill is written—the service users and the carers—that the Government will think again about the decision not to include in the Bill a duty on the Secretary of State to take well-being into consideration.

[Baroness Pitkeathley]

My Lords—

Care Bill [HL]

Baroness Jolly Excerpts

Wednesday 3rd July 2013 Lords Chamber

[Noble Lords]

Order!

[Baroness Jolly]

I will be brief. I support the amendment in the name of the noble Lord, Lord Rix, on preventing needs for care and support for those with learning disability. We need to remember that those for whom the Bill is written are all vulnerable adults: whether they are vulnerable by virtue of their age; their learning disability; mental state; physical condition, whether that is disability or frailty; whether they are living at home or in other accommodation. A local authority should take all steps it considers will contribute towards adults experiencing, or being put at risk of, abuse or neglect. We have just heard about preventive measures: these are preventive measures linking in with needs. The outcome of the amendment would be a reduction in incidents of neglect or abuse. It might mean local authority employees raising concerns about individuals or organisations providing care; making it a regular agenda item at a team meeting and not turning a blind eye; whistle-blowing where appropriate and making it part of the well-being culture.

Before I saw the regroupings, I had also intended to speak to the amendments of the noble Lord, Lord Best, which were, at one time, grouped together. Amendment 88 seems to have become an orphan amendment within this group. I support it but I will speak to it when the rest of the amendments are dealt with.

NHS: Mid-Staffordshire NHS Trust

Baroness Jolly Excerpts

Monday 24th June 2013 Lords Chamber

[Earl Howe]

My Lords, the noble Lord raises a very current issue. As he will remember, we have introduced a contractual duty to raise concerns. We have issued guidance to NHS organisations on that subject. We have also strengthened the NHS constitution to support staff in the NHS and in social care on how to raise concerns. There is a free helpline to enable them to do that. We are considering in the context of the Care Bill the whole issue of the duty of candour. I feel sure that the noble Lord will make a valid contribution to that debate.

[Baroness Jolly]

My Lords, communication of complex issues is a vital part of any press department’s role. Will my noble friend the Minister tell the House how large the press teams within the Department of Health and NHS England are, how much they cost the taxpayer and how their effectiveness is managed?

[Earl Howe]

My Lords, the latest figure that I have for the cost of the Department of Health’s media centre is for 2011-12 and is £2.57 million. I will write to my noble friend as soon as I have more recent figures. She may be interested to know that the names and contact details of each of the department’s press officers are published on the GOV.UK website. Currently, 28 Department of Health press officers are listed there. I do not have to hand the details of the number of press officers employed by NHS England, but, again, I shall write to my noble friend with that information. In the department and in NHS England, internal line management arrangements are in place to measure performance.

Health: Children's Heart Services

Baroness Jolly Excerpts

Wednesday 12th June 2013 Lords Chamber

[Earl Howe]

I hope that my noble friend will be reassured by the IRP’s recognition that the location and geography of these centres and where they are in the country are material factors in this equation. At the same time, I think it would be wrong to give the impression that one can establish a centre of expertise of this kind in every city; that is clearly not realistic. Merely because there is a certain density of a population in a location does not mean to say that there can be a children’s heart centre very close to the centre of that population. This is a highly specialised service and we must recognise that the centres that will deliver it will be few in number. Nevertheless, I am sure that the message that my noble friend has given will not be lost on NHS England.

[Baroness Jolly]

My Lords, it is critical that however NHS England proceeds, it does it openly and transparently. I welcome the Minister’s comments on that. Will he also agree that meetings of any review body should be advertised, public and make all necessary papers available to the public?

Care Bill [HL]

Baroness Jolly Excerpts

Wednesday 12th June 2013 Lords Chamber

I turn to Amendments 61 and 62, in the name of the noble Lord, Lord Willis of Knaresborough. He is now at home and recovering. He has been asked to rest for about a month or so, if his family can manage to keep him down, but he is well and his treatment is going well. His son sent me an e-mail about it; our good wishes are doing the trick. Amendment 61 merely says that those who deliver patient care for NHS patients should be treated in the same way as NHS trusts. That cannot be wrong. Surely there is an omission. Amendment 62, to which the noble Lord, Lord Turnberg, referred, replaces “have regard to” in the Bill with “comply with”. What does “have regard to” mean? Surely those bodies must have to comply with directions given by the HRA. I hope the noble Earl will respond to that.

[Baroness Jolly]

I will speak briefly in support of Amendments 59, 61 and 62. We have had this debate about lists—sometimes they are good, and sometimes not. There is no way of knowing when they are good and when they are not. However, I welcome the additions suggested in the amendments, in particular the amendment in the name of the noble Baroness, Lady Emerton, on the Chief Nursing Officer. That is absolutely critical. Everybody knows about doctors, but the amendment sends out the key message that nurses play a role in collecting an evidence base to improve care for patients. That is very important. I have seen some very nice research done by nurses, who work in the community, about care. That really makes a difference and, of course, it is then shared among their colleagues.

I will also speak briefly to Amendments 61 and 62, in the name of my noble friend Lord Willis. These are about the guidance that the HRA produces and who should pay heed to it. Here we have a mini-list, but the not-for-profit and private sectors were missing from it. Anybody who does work for the NHS should be included. The wording should be strengthened from “have regard” to “comply with”. It currently makes no sense whatever. I would be grateful if the Minister can confirm that.

[Lord Turnberg]

My Lords, I am sorry to rise again, but I have a very brief question. In a clause dealing with promoting regulatory practice, why is the Secretary of State No. 1?

Health: Midwives

Baroness Jolly Excerpts

Monday 10th June 2013 Lords Chamber

[Earl Howe]

My Lords, some of them already do. As I understand it, we are talking about 154 individuals as compared with 41,000 midwives on the register. If they work for the NHS, there is generally no issue; they will be covered by NHS indemnity in one way or another. The issue is if they wish to practise privately as individuals. That is the point of my noble friend’s Question.

[Baroness Jolly]

My Lords, there is a certain element of urgency here. A woman expecting her baby in October would be half way through her pregnancy now. What plans are in place to deal with such women under the care of these midwives and indeed the midwives themselves if, come October, the situation has not been resolved?

[Earl Howe]

My Lords, we are working hard on this. Officials from the department have been in discussion with stakeholders, including Independent Midwives UK, on an ongoing basis for at least four years with a view to identifying potential solutions to the issue. Arising in part from these discussions, independent midwives can now obtain affordable indemnity cover for the whole of the maternity care pathway either in the NHS or in the private sector. However, it is acknowledged that this is achievable only if they operate as part of some form of social enterprise or corporate entity. That is the issue that we have to get to grips with between now and October.

Care Bill [HL]

Baroness Jolly Excerpts

Monday 10th June 2013 Lords Chamber

[Lord Patel]

My Lords, I support these amendments. My name is attached to Amendments 17, 20 and 32 in the name of the noble Lord, Lord Turnberg, and to Amendments 37 and 39 in the name of the noble Lord, Lord Willis of Knaresborough, who, as we have heard, was taken to hospital yesterday. I spoke to him in his hospital bed just before we started and he was beginning to feel better. I am sure we will want to wish him well.

I strongly support the amendment because, through the Health and Social Care Act, we gave prominence to the need to promote research and innovation in the health service, and it is right that we did that. It would be a pity now if the only gap in that duty would be for it not to apply to the key body, Health Education England, and the local education and training board committees. As the noble Lord, Lord Turnberg, so eloquently put it, the amendments are about education and training by research, and about making sure that LETBs also have a responsibility to make sure that they conform to the functions of the HEE. They are all related to research, training, innovation, continuing training and research and supporting research. They cannot be wrong and I hope the Minister will accept them. They are well meaning and promote research further.

[Baroness Jolly]

My Lords, I thank the noble Lords, Lord Turnberg and Lord Patel, for helping me with these amendments. The noble Lord, Lord Willis of Knaresborough, is unwell and may not be returning to us in time to help with the Bill. His twin passions are training and research, and Amendments 37 and 39 to Clause 90, which are all about the functions of LETBs, completely underpin that. I would be doing him a disservice if I did not ask the Minister to explore these areas when he sums up.

It is critical not only at a national level, with HEE, but at a local level, with the LETBs, that this area is not forgotten. Staff must understand not only the implications but all aspects of research. That must be plugged in at HEE and, with these amendments to Clause 90, at the LETB level.

[Baroness Wheeler]

I strongly support this group of amendments, the case for which has been ably made by my noble friend Lord Turnberg, the noble Lord, Lord Patel, and the noble Baroness, Lady Jolly.

The importance to the NHS of research and innovation has come under close scrutiny and debate in the House in recent times, under the Health and Social Care Bill, in the powerful debate of the noble Lord, Lord Saatchi, earlier this year, and in the debate that we almost had in the name of the noble Lord, Lord Kakkar, on the life sciences industry’s important contribution to healthcare and to our economy.

Under the Health and Social Care Act, Labour fully supported placing duties on the Secretary of State, the NCB and CCGs to promote research. Indeed, my noble friends Lady Thornton and Lord Hunt proposed amendments to that Bill reinforcing the importance of research, and we were pleased to work with noble Lords across the House in strengthening these provisions. That is why amendments to Clause 86, which deals with quality improvement in education and training, are so important.

Amendment 17 deletes the current reference to HEE needing to promote,

“the use in those activities of evidence obtained from the research”,

and replaces it with a proactive reference to using this,

“evidence to ensure the rapid uptake of innovations into practice”.

Amendment 20 underlines the need for HEE,

“to secure that research and innovation are incorporated into education and training”.

This was a recommendation of the Joint Committee, which we fully support. All NHS staff should be equipped with the tools to understand and support research and to assess and use evidence to inform their decisions when caring for patients or supporting clinical staff. They also need to be able to make use of research throughout their careers—a point that my noble friend Lord Turnberg made strongly—and be familiar with the NHS research infrastructure, which can provide further help and support.

The recent survey by the Association of Medical Research Charities showed the challenges to be phased in in this regard. Some 91% of staff surveyed, including doctors and nurses, identified the barriers that they had experienced to taking part in research. Lack of time was the predominant reason given by respondents. Other reasons included funding, practical support and difficulties in navigating regulation. GPs are an important gateway for getting patients involved in research, but although a majority of GPs believes that it is important for the NHS to support research into treatments for their patients, only 32% felt that it was important for them personally to be involved. As AMRC emphasises, we still have a long way to go if the Government’s goal of every clinician being a researcher and every willing patient a research participant is to be achieved.

Amendment 32 to Clause 87 adds promoting innovation and research in clinical practice to the matters that the HEE should have regard to—a logical and crucial next step in our support for innovation and research under HEE’s national functions. Amendment 37 on the local functions that LETBs exercise on behalf of HEE makes the important cross-reference between Clause 90 and Clause 86, rather than Clause 84, on the issue of ensuring that there are sufficient skilled healthcare workers promoting research and the use of research evidence in the health service. We believe that if LETBs are performing other duties of behalf of HEE under Clause 90, there is no reason why they should not also promote research, obviously within the LETB area. Amendment 39 would confirm in legislation that HEE’s research duty applies to LETBs as a main function, and we strongly support that.

Throughout the debates on innovation and research, we heard continued concerns and frustrations at the often painfully slow, complex and bureaucratic process of getting innovation in care and treatment adopted in the NHS. There was frustration, too, that existing processes and pathways, such as conditional approval in the named patient schemes and the opportunities under existing legislation, are not being fully used. In the January debate, the Minister reminded us that it took an estimated 17 years for only 14% of new scientific discoveries to enter day-to-day clinical practice. That is why these amendments to ensure that HEE actively promotes innovation and research and carries that through in the education and training of healthcare workers needs to be supported by the Government. I look forward to the Minister’s response.

Care Bill [HL]

Baroness Jolly Excerpts

Monday 10th June 2013 Lords Chamber

[Lord Patel]

My Lords, I have added my name to both these amendments in the names of the noble Baroness, Lady Emerton, and the noble Lord, Lord Willis of Knaresborough, and I strongly support the principles behind both. The key issue here is that a training curriculum should be developed by the Nursing and Midwifery Council, as the amendment says. In a way—to pre-empt the Minister regarding what the Cavendish review might recommend—whatever the review recommends will have to be taken on board by whoever develops the curriculum. Although the Cavendish review is not defunct, the principles of this amendment are not based on what it might say. Presumably the review will focus on the necessity for training and the kind of training that support and healthcare workers should have. These amendments put a duty on Health Education England to make sure that a curriculum is developed.

The other important point is that the training should be mandatory—not the training curriculum but the training—and the employers must ensure that they employ only those who, having been trained, hold a certificate showing that they have completed it. It is just the same as I would have to do when seeking employment at a hospital. I would have to produce a degree certificate from a university proving that I have been trained as a doctor before they will employ me. It would be an offence to do otherwise. The amendment does not provide for a penalty but that issue will have to be addressed. Although “register” might be the wrong word, the implication is that the employer should be obliged to keep a list of all the healthcare support workers in its employment who have completed the mandatory training and hold a certificate.

The completion of training and the holding of a certificate are the key issues. As nobody can be employed unless they have done that, the care for patients will be safer. The process will define the competencies of these people. It will define what further development they have to go through professionally to be able to do other tasks. It will also make the life of the supervisor easier as they will know what competencies these people have and they will not delegate to them tasks which are beyond their competencies. In that respect, these amendments fulfil all the requirements that the Francis report and several other reports have alluded to—the need to make sure that we have a fully trained and competent workforce which delivers front-line healthcare. I hope that the noble Earl takes the amendments in that spirit.

[Baroness Jolly]

My Lords, I want to add quickly to what has been said by the noble Lord, Lord Patel, and the noble Baroness, Lady Emerton. I very much support what they said. What I can add over and above that is that the amendment in the name of my noble friend Lord Willis, Amendment 23A, refers to,

“working directly with patients or clients”,

so it works not only in a health context but in a care context.

I will declare my mother—as the noble Lord, Lord Campbell-Savours, did his—as an interest. She is a lady who I visit regularly and is well over 90. Somebody comes to see her in her home every day—for the most part they are very nice young women—but I have no idea where they come from or what training they have. Amendment 23A would give me confidence that they have been trained and are certificated. Furthermore, these people tend to be quite a mobile population. If their certificates were to follow them from one establishment to the next, it would give the next establishment confidence that their training had been delivered to the right standard and that, all other things being equal, it is appropriate to employ them. That adds weight to Amendment 23A.

[Lord Campbell-Savours]

In speaking to a previous amendment, my noble friend Lord Hunt produced the explanation, which I am sure is true, that the reason that the Government are being tardy in the area of registration, which is obviously linked to training, is money. I argue that it is actually more costly not to act in this area than to ignore the problems that inevitably arise where there is an untrained workforce in an area where life and death are of critical importance. I do not exaggerate.

I think I have said before in health debates that I probably spend more time in bed on hospital wards than a large number of noble Lords put together. I have seen all kinds of things in hospitals over the years. You never say a word because you are grateful that you are there. You cannot complain. You watch. When you are an MP or a Member of this place you watch with a view to one day perhaps being able to raise what you have seen in a forum where people might actually listen and deal with it. There are many people who leave hospitals today and do not say a word. If they are cured and feel better, they feel grateful, even though they have seen things that they know are wrong.

I argue that many of the problems that arise on hospital wards arise as a result of insufficient training of healthcare assistants. They are in the low-paid sector of the social care and the acute hospital worlds. Many are on the national minimum wage. I will have to do a little more work on vetting and barring. I must admit that I do not know a lot about that. However, it seems to me that somehow people are allowed to enter into this sector who should not be there. I have seen them at work over the years.

I will not name the hospital, but I remember being on a ward where they needed to put strapping across my chest to do an ECG. It was around 1 am or 2 am. A healthcare assistant brought five machines to my bed. The first four machines all appeared not to work. The healthcare assistant then found a junior doctor on the ward. It turned out that the healthcare assistant just did not know how to use the ECG machines. They had not been trained properly. Think of the loss of time involved; of my frustration at 2 am, or whatever time it was—it is several years back now—at having to wait while all this was going on. There was also disruption for the patients in the beds to each side. They could not sleep because of the commotion. They knew that something was happening. The lights were off. There was only a light at the end of the ward where the nurses sit. The curtains were pulled around the bed. People kept going back and forth trying to find out why this piece of equipment was not working. In the end the problem was solved.

I think that there are many areas not only in social care but also in the private social care sector where little things that are of immense importance to patients could be dealt with if only the healthcare assistants available actually knew what they were doing and understood the importance of what they were doing to an individual patient. I shall refer to just a few of these areas. We have heard of food out of reach. I have seen that repeatedly in hospitals. I have seen it in other settings as well. An elderly person may be trying to get hold of something but they cannot communicate. They can only wait for someone to turn up. That person will not be a nurse, because the nurses are invariably sitting behind a desk trying to sort out the huge amount of paperwork that they have to deal with, or a doctor, because the doctors are running back and forth. Their problem may be the jug of water, the uncomfortable bed, the extra pillow, the extra blanket to keep warm, the dirt on the floor, the fact that they have not been cleaned or, if they manage to get to the toilet, the toilet not being properly cleaned. Many people might say that that is down to ward management, but the fact is that everyone on the ward is under pressure and very often it is not the nurse or the ward leader who is held responsible, but the poor young woman or man who is paid very little money who is taking the brunt of the anger of the patient. I do not think that that is good enough. I very strongly support these amendments as their purpose is to tackle the problem of the quality of care that is given by people who are hands-on in the ward.

We have talked about standards. I think that communication is extremely important. I have been on wards where the patient could not talk to the healthcare assistant because the healthcare assistant could not speak English. Can you imagine the frustration of the ill patient who cannot communicate with the healthcare worker because they do not understand what the patient is saying? I think that it is essential that language, and the ability to communicate through language, is a part of the training programme, to ensure that we are not bringing in, particularly from the banks and agencies, people who should not be on the ward. Some of them are, in my view, a danger to patients.

I think that there should certainly be training for healthcare assistants in nutritional requirements and why nutrition is important. As the noble Baroness, Lady Emerton, said, it is necessary not just to say to someone that this is what they must do; they must also understand why they are doing it and the significance of that to the patient. There should also be training in ward hygiene and training in the use of equipment. There should be training in how to take blood pressure. On one occasion I had my blood pressure taken by a person who did not know where the tube had to come out of the arm strap. I had to tell that person that it was on the wrong way. I have been in Parliament; of course I could tell them. What about the patients who do not know how to take blood pressure and may well get a wrong reading? That must change.

There should be training in the need to ensure that bedding is fresh and clean and on the turning of patients. Patient turning is very important on a hospital ward, as the Minister must know. However, it is very often the case that healthcare assistants have not been adequately trained in the way that a patient is turned on the bed. There must also be training in ward hygiene and in the standards required of a hospital loo. I have been in hospitals where the loos have been filthy. You would not think that there would be such filth in a hospital in the British National Health Service—things still in the bowl, floors not cleaned. I am not exaggerating. It is going on within the NHS.

A colleague and good friend in the House of Commons, Ann Clwyd, is doing some work on complaints, as the Minister will know. I go to her office regularly as we work in some of the same areas. I obviously cannot be involved in the work that she is doing on behalf of the Executive, but I do know about the speeches that she is giving in the House of Commons, involving personal testimony coming in from all over the country. She has read to the Commons from some of the letters she has received—not hundreds but, as the Minister will be aware, thousands—underlining all the complaints about the NHS. She has almost become the national clearing house for complaints. Many of those complaints are not about sophisticated areas of healthcare in hospitals. They are about very elementary things with which, with a little bit of thought, a healthcare assistant or a nurse could deal if only they had been properly trained in that area.

We know that the trade unions, particularly Unison, have made their voice very clear on this issue. They want training and registration. I understand that that is the position of the RCN. Most of the health service organisations want it and many healthcare assistants recognise the value of it. The Minister may not concede today but I plead with him to go back to his department and tell some of the civil servants who work with him on these matters that something has to change. I do not believe that this sort of laissez-faire attitude to this sector of healthcare is the answer. It is for Ministers in this Government to take action now and resolve the problem. There is a crisis and it has to be resolved.