Women: Board Membership

Baroness Pitkeathley Excerpts

Monday 17th June 2013 Lords Chamber

[Baroness Northover]

We are indeed pleased at the progress that is being made but the noble Baroness is absolutely right, as is the previous noble Baroness, that progress needs to continue. The Prime Minister said in February 2012 that further action has to be considered as a back-stop and Vince Cable said in April 2013 that the Government would, if necessary, adopt tougher measures. The warning is there. If there is continued progress, that is great. If not, there are sticks.

[Baroness Pitkeathley]

Does the noble Baroness agree that one of the problems is that the boards are not sufficiently flexible in what they see as the requisite experience for serving on boards? For example, many women who hold senior positions in the voluntary and charitable sector are never considered because their experience is not considered relevant.

[Baroness Northover]

The noble Baroness is right, and boards need to take a wider view in terms of the experience and expertise that are there. I should like to quote one of the remaining FTSE 100 companies, Melrose, which still has an all-male board. It is,

“a leading British-based investment company specialising in the acquisition and performance improvement of underperforming businesses”.

There are no women on its board. How is it to ensure that companies are geared to the 21st century if it is so outdated in its own approach?

Equality: Pay and Opportunities

Baroness Pitkeathley Excerpts

Thursday 8th March 2012 Lords Chamber

[Baroness Northover]

My noble friend is absolutely right. Gender stereotyping in schools has tended in the past to direct girls way from the areas that she is talking about. The new National Careers Service will encourage girls and young women to challenge those stereotypes and encourage them to choose from the broadest possible career options. That includes providing good information, which girls, certainly from my experience, are very interested in, about the wide range of career opportunities that studying science and maths can lead to.

[Baroness Pitkeathley]

My Lords, does the Minister agree that, with the demographics of an ageing population, the provision of elder care and care for disabled people is just as important, if not more important, than the provision of childcare in enabling people to return or stay in the workforce? What provisions are the Government making to help people with caring responsibilities enter or remain in the workforce?

[Baroness Northover]

The noble Baroness is absolutely right. We often debate how we can better develop the support of social care. I look forward to future debates this year on that area, as she knows. She is quite right that many people find themselves trapped in a situation where they are responsible both for the care of children and for elder care. That means that it is extremely important that our extension of the right to request flexible working for all employees—men and women, as we seek to share that responsibility—is taken forward. It is very important that this does not simply fall on women. At the moment, many men support their parents as well, so I hope that this is something that will move forward steadily.

Health and Social Care Bill

Baroness Pitkeathley Excerpts

Monday 19th December 2011 Lords Chamber

[Baroness Pitkeathley]

My Lords, I am very sorry to take issue with the opinions of noble Lords with whom I usually agree most heartily. I remind the Committee of my role as chair of the Council for Healthcare Regulatory Excellence. I should make it clear that I am in no way taking issue with noble Lords' concerns about the practice of healthcare assistants, nor with the emphasis—given particularly by the noble Baroness—on the need for proper training. The only thing I take issue with is whether statutory regulation is the correct solution to the problem.

I am not aware of any body of evidence that demonstrates that the risks of future harm presented by the practice of healthcare assistants could not be successfully managed by the existing processes and governance systems if they were applied effectively. That is the point. Healthcare assistants are already supervised by other staff who have the professional responsibility to supervise them. As we have heard, they almost always work in supervised settings, with supervision usually being the responsibility of staff who are statutorily regulated. Statutorily regulated professionals have a responsibility to ensure that the staff whom they manage offer safe care, conduct themselves professionally and are delegated only tasks that are within their technical competence. For example, the Nursing and Midwifery Council’s code states:

“You must establish that anyone you delegate to is able to carry out your instructions … You must confirm that the outcome of any delegated task meets the required standards … You must make sure that everyone you are responsible for is supervised and supported”.

In other words, we already have in place a governance system to ensure that healthcare assistants work safely and with proper delegation, supervision and support from a statutorily regulated professional. Employers are required to ensure safe systems of work, which will include providing support in delegating and supervising effectively.

Creating a list of people is not in itself an effective safeguard. Effective regulatory conditions are often much closer to home. For example, in an environment that is poorly managed and distant from scrutiny, poor standards of care can become the norm, with staff being drawn into collusion with poor care. We have seen many examples of this recently, particularly of the process of collusion, with people working in a poorly managed environment unable to resist the downward spiral of standards. The most effective way to invert the spiral is by employers properly managing the specific environment, not by establishing another structure.

Winterbourne View was referred to several times in this short debate. Perhaps it is worth reminding noble Lords that registered professionals were involved in delivering poor care there. Statutory regulation did not prevent it. We should always bear that in mind. Regulation is not necessarily the answer. Further, we cannot ignore the fact that statutory regulation would be expensive and cumbersome for a large, low-paid workforce with a high annual turnover. It is not proportionate to the risk, which can be managed by effective training, delegation and supervision.

The recent announcement by the Secretary of State about improving standards of training and the potential to develop a voluntary register of healthcare assistants is encouraging. I also welcome the Nursing and Midwifery Council's announcement that it will fully engage with the project that the Secretary of State announced, and with any further developments around assured voluntary registration for this particularly valuable group in the healthcare workforce. It is important that we make sure that we value this group, who are of such importance in the front line of the nursing and patient care environment.

[Lord Warner]

My Lords, I am speaking because my name is also on this amendment. We need to reflect on several aspects relating to the context of this issue. I do not think that there is much doubt that we have a problem of some significance, or any doubt that the problem has been growing over a long time. I also do not think that it is an easy fix simply to jump to statutory regulation. I went through the process when the whole issue of regulating social workers arose, and that proved extremely difficult to introduce. I do not doubt that we will end up with statutory regulation of some kind, but we might have to go through some processes before we get to that point.

I do not want to duplicate the history that other noble Lords have put forward most expertly. I came into this story as a very young civil servant at the end of the 1960s when the Salmon committee was set up. Some noble Lords may be old enough to remember the Salmon committee—I was assistant secretary to the committee. This was in the days when civil servants could not hold a job for long and were moved on at a tremendous rate. While doing this work we saw how things worked at the ward level. In those good old days of the 1960s and early 1970s there was a ward sister, state-registered staff nurses, nursing auxiliaries and state-enrolled nurses. We also had a set of arrangements in which oversight of cleaning was largely the duty of the ward sister. Furthermore, bank working was not that common.

What has happened since those “good old days” is that hospitals have become used more intensively. Bank working has meant that there is a higher flow of different people moving through the wards, and the profession, with good reason, has wanted to make itself a graduate profession. The context has changed a lot, so the dynamics of those wards has changed quite a lot.

Alongside that we have been growing another industry in the community: in nursing homes, residential care homes and—not quite as fast as one would like, within the health service—a district nursing service. One of the problems in both these areas, whether acute hospitals or the community, is that with the demand of patients for services, and the demography which has gone alongside that shift in time, the qualified and registered nursing profession has inevitably had to look for help from sub-professional groups to help carry the load. In the community there is not a strong management structure to oversee this, so to some extent it is difficult for district nurses to oversee any work done by unqualified personnel. Such oversight might be the theory but in practice it will often be difficult to achieve.

Community services are burgeoning, the hospital service has changed, and we have a problem of a growing need for more people who are not qualified and registered nurses to work alongside such nurses to provide some of the care. We are looking to the Government to produce a comprehensive review that examines the situation that we face now rather than the situation we faced 10 or 15 years ago and which was very different.

I suspect that we will have to move by interim steps towards statutory registration, and perhaps voluntary registration is an interim step. However, I am not convinced that we have a comprehensive set of answers to a continuing and serious problem. The Government need to think about how they will deal with this very serious problem.

--- Later in debate ---

[Baroness Finlay of Llandaff]

My Lords, this group of amendments is very interesting as it reveals the enormous number of people involved in healthcare who literally hold the lives of others in their hands and are not subject to any statutory regulation but are voluntarily registered. I have an amendment in this group which seeks to establish,

“a statutory register of Physicians’ Assistants (Anaesthesia)”

and of other healthcare professionals. I will speak about that in a moment in relation to clinical perfusion scientists.

Physicians’ assistants in anaesthesia already have a voluntary register in place and they applied to the Health Professions Council for registration and had their application accepted. However, that all went on hold with the emergence of this Bill. The Royal College of Anaesthetists does not allow physicians’ assistants in anaesthesia to become associates as they are not registered with the General Medical Council, but it permits them to have affiliate membership. However, the college does not have a regulatory role as such; it is tied up with education and standards.

Physicians’ assistants in anaesthesia urgently need statutory regulation, given the range of invasive, and potentially life-threatening, procedures that they perform and the knowledge and autonomy of practice required in the roles that they carry out. These practitioners perform tasks that, in the UK, were previously carried out only by doctors. They cannot get indemnity insurance for their practice or apply for prescribing rights, even though they sometimes have to be able to respond in a matter of seconds, not minutes, if something goes catastrophically wrong with an anaesthetised patient while the anaesthetist is outside the theatre for whatever reason. They are on a voluntary register, which provides some reassurance for patients and employers, but that cannot realistically be seen as an alternative to statutory regulation. I think that in 2009 they were identified by the Department of Health as being urgently in need of registration. The Health Professions Council felt that these assistants fulfilled sufficient of its criteria to warrant the recommendation for statutory regulation being accepted.

Irrespective of whether Members of this House have undergone a procedure requiring anaesthesia, would they consent to being rendered unconscious by an individual who was neither bound by a stringent professional code of conduct nor properly registered to practise? After all, we would not get into an aeroplane if we did not know that both the pilot and the co-pilot were appropriately qualified to a very high degree, with ongoing continuing professional registration. We trust them just as we trust these physicians’ assistants, but if something goes wrong in theatre it does so with catastrophic rapidity. When I did my training in anaesthesia, on more than one occasion I saw these physicians’ assistants recognise problems arising before the trainee anaesthetists had done so. They carry enormous responsibility during complex procedures.

I have included other healthcare professionals in my amendment as I am well aware that the Government do not like to have enormous lists in a Bill. My amendment would therefore leave the door open to include clinical perfusion scientists—the other group involved in theatre—whose role is primarily to maintain a patient’s circulation during open-heart surgery, during a period of surgical repair when the heart has been stopped. They were recommended in 2003 for statutory regulation.

There have been two high-profile cases involving clinical perfusion scientists. The first fatality, in 1999, led the Southwark coroner to recommend the immediate statutory regulation of clinical perfusion scientists. The second fatality, in 2005, was attributed to inappropriate drug administration by a clinical perfusion scientist during an operation on a five-month-old baby at Bristol Royal Infirmary. That led to the publication of the Gritten report, which concluded that:

“The incident occurred because of latent weakness that lay dormant for years hidden by healthcare professionals compensating for inadequacies within national and local systems”.

The report recommended that action at national level should include,

“regulation and guidance on perfusion practice in cardiopulmonary bypass”.

More recently, there have been fatalities that have led to clinical perfusion scientists’ actions being questioned by coroners—the most recent of these incidents occurring in 2010 at Nottingham City Hospital.

I do not want to scare people from going in for surgery and I do not want to scare Members of this House who may be going in for surgery, but in the current climate people need to know that these very critical roles are being undertaken by people who are on a voluntary register but do not enjoy indemnity, as they would if they were on a statutory register and subject to the rigours of being statutorily regulated.

[Baroness Pitkeathley]

My Lords, I do not want to sound like a broken record in always resisting more statutory regulation or in disagreeing with colleagues with whom I normally agree, but I want to emphasise the application of light-touch regulation. We should use only the minimum regulatory force to achieve the desired result. Therefore, we should be considering extending regulation only where the risks to patient safety and public protection are such that other mechanisms such as those I previously mentioned—employer’s guidance, clinical governance, appropriate delegation and multidisciplinary teamworking—are unable to manage those risks.

When the Council for Healthcare Regulatory Excellence becomes the Professional Standards Authority for Health and Social Care, it will be accrediting voluntary registers as a more proportionate and targeted approach to developing high standards of care for people working in health and social care who are not statutorily regulated. I remind your Lordships that statutory regulation can be expensive and it is important that we explore and develop a range of options for maintaining and improving the quality of care delivered by people working in health and social care. It may be more proportionate, for instance, to promote greater co-operation and sharing of good practice. We seek to find the most efficient and common-sense solutions to the kind of problems that your Lordships have identified.

[Baroness Oppenheim-Barnes]

What proportion of voluntary persons employed in operating theatres are expected to be affected? Is it not the case that the great proportion of them are specialists who are subject to statutory regulation?

[Baroness Pitkeathley]

Currently, a great proportion are in statutory regulation, given that voluntary regulation is being developed. The CHRE is currently working on that.

Health and Social Care Bill

Baroness Pitkeathley Excerpts

Wednesday 16th November 2011 Lords Chamber

[Lord Kakkar]

My Lords, I shall speak to Amendment 83 in my name and that of my noble friend Lord Patel. This amendment proposes that:

“Regulations must require the Board to commission services for veterans who have lost limbs”.

The purpose of the amendment is to ensure that those who have served our nation and who have quite rightly received the highest standards of care—both in theatre in the battlefield at the time when they sustained horrific injuries, then during their immediate aftercare back here in the United Kingdom and thereafter while remaining members of the Armed Forces receiving ongoing rehabilitation—can be certain that, once they are discharged from the services and return to civilian life, they are able to avail themselves of the necessary specialist services for years and decades hence. There is no doubt that what is achieved in battlefield salvage is quite remarkable, and those who sustain horrific injuries that some time ago would not have been survivable are now saved and can continue, from a young age, with the prospect of a good quality of life. However, the injuries, particularly the limb losses and multiple limb losses that they have suffered, will require ongoing specialist care.

Her Majesty’s Government have recognised the importance of this area and the noble Earl’s honourable friend the Member for South West Wiltshire, Dr Andrew Murrison, has recently published a report, A Better Deal for Military Amputees, in which he reviews both what is achieved acutely for these brave servicemen and what their ongoing clinical and other needs may be. He makes a number of important recommendations in the report. He suggests that a nationally commissioned service for veterans is the best fit for service-attributable amputees and, of the options he puts, looks at the option most likely to deliver the most for the wider amputee community. He goes on to make a specific recommendation that:

“Ministers should take appropriate powers to provide for national commissioning of specialist prosthetic and rehabilitation services for amputee veterans through a small number of multi-disciplinary centres in England, adequately resourced and determined through a tendering exercise”.

He puts the question that:

“Ministers will have to consider the extent to which existing legislation and the Health and Social Care Bill which is currently before the House of Commons”—

it was at the time—

“permit the national specialist commissioning of special provision for amputee veterans, tabling any necessary secondary legislation or amendments to Clause 11 in the Health Bill”.

So there is a broad recognition by those who have been commissioned by Her Majesty’s Government to look at this issue. The commissioning of specialist services for amputee veterans to ensure their long-term good clinical outcomes—that they may avail themselves of advances in the future, which are going to be dramatic and important in the decades hence and which could have an important impact on their ability to function—and that they have a high quality of life will only be achieved through national specialist commissioning of amputee services.

The Prime Minister, in his response to the report, stated the following:

“I am passionately committed to our Armed Forces. As a country and as a Government we have a particular duty to servicemen and women injured on operational duty. This report maps out a clear strategy for ensuring that those brave people can be confident they will receive the same levels of access to prosthetic limbs and specialist care from the NHS as they do at Headley Court. They deserve nothing less. Based on the recommendations in this report, this Government will make the resources necessary to meet that need”.

This amendment provides an opportunity to ensure that those needs are met. I strongly believe that only through the specialist commissioning of these particular services will the long-term interests of our brave service personnel, who have lost multiple limbs and who have to contend with that in their veteran lives, be properly secured. I hope very much that Her Majesty’s Government and the noble Earl will consider this amendment seriously.

[Baroness Pitkeathley]

My Lords, having put my name to Amendment 79, I support the powerful case made by my noble friend Lord Warner for the inclusion of long-term conditions and integrated services in the Bill. I particularly draw your Lordships’ attention to those long-term conditions that can be fluctuating as well as progressive. While it may be progressive in an overall sense, an illness such as multiple sclerosis has periods of varying intensity, when needs are different, and even periods—sometimes quite long periods—of remission. It is very important, therefore, that services are not only commissioned across health and social care—it is very important that there is a whole package of support; that is of such significance to users and their families—but also that those packages of care are flexible enough to cope with the varying progress of these illnesses.

The last thing that an MS sufferer, for example, wants when a period of remission suddenly ends with a fresh attack, as it frequently does, is to go back to square one on clinical commissioning, especially as far as the integration of clinical and social care commissioning is concerned. They do not want to go back to starting the assessment process or back to judgments about need and the abilities of their families to care for them, and so on, with all the delays and distress associated with reassessment and all the unnecessary expense that these processes involve. That applies very much also to those with certain mental health conditions, which are also fluctuating in their intensity. So proper care across integrated services not only prevents acute episodes but also helps to support caring families to participate in care effectively, as they wish to do, thus saving scarce resources as well as meeting the needs of those who are suffering.

[Lord Cotter]

I shall speak to Amendment 81B, to follow on from what the noble Lord, Lord Hunt, said. Brevity will be my watchword, of course, because we do not wish to drag out proceedings. This is a particularly important amendment, referring as it does to commissioning for rare conditions. There are many such rare conditions that people suffer from, but I refer particularly to one called arthrogryposis, which my wife has suffered from from birth to today. As with many people who have struggled with a rare condition from childhood to the age she is now, it has been difficult to get not just treatment but diagnosis. She was originally not diagnosed with this condition, which is associated with the nervous system and the muscles and mobility. Throughout her life she had the difficulty of being misdiagnosed, and then when she was diagnosed she had difficulty getting treatment. I welcome the amendment for that reason.

Many people have that struggle to get the treatment that they need appropriately in their area. For example, we recently went to Birmingham, where they have done some research work. It is so important to get research work done for rare conditions, to establish where they came from and whether people were born with them. I so much welcome—as my wife and others with her condition will welcome, as well as those with other conditions of various sorts—the fact that we are drawing attention to the need for commissioning for rare conditions. You could say that only a small proportion of the public has each rare condition but, when you add all the rare conditions together, there is quite a proportion of people with those problems.

I draw to a close on that basis and hope that the Minister will consider this very carefully, as we and many other people have had experience of rare conditions, with the difficulty of diagnosis and treatment and of getting it recognised throughout their lives.

Health: Cancer

Baroness Pitkeathley Excerpts

Thursday 11th November 2010 Lords Chamber

[Baroness Pitkeathley]

My Lords, I thank the noble Baroness, Lady Finlay, for securing the debate. No one is more fitted to lead such a debate, and it is a privilege to take part. It is a privilege, too, to speak in your Lordships’ House from personal experience. It is even more of a privilege that, thanks to the expertise and dedication of NHS staff at many levels, I am alive to participate, as I have twice recovered from cancer—although on the second occasion it was a very close run thing.

As well as to that expertise and dedication, my recoveries—in the plural—can be put down to two things: early diagnosis and proper follow-up care. On early diagnosis, I am delighted that I share the view of the noble Baroness and of Professor Mike Richards, the cancer tsar. He was recently quoted as saying:

“if you wanted to sufficiently change outcomes from cancer I would not spend £200 million on expensive cancer drugs; I would spend it on earlier diagnosis and involving GPs”.

That was certainly my experience.

The first time that I was found to have cancer was due to the vigilance of my GP, as I had virtually no presenting symptoms; he just had an uneasy feeling that something was wrong so he sent me to see a consultant. The second diagnosis was made no less than 14 years later as a result of the screening that I was still having, although, admittedly, only occasionally. On that occasion, another primary cancer was detected in another part of my colon. I was considerably more ill the second time and spent a long time in hospital, but the important thing was that all the cancer was removed. Although I was constantly back and forth between intensive care and the ward, there was excellent liaison among all parts of the system.

In this context, I want particularly to mention the work of patient emergency response teams, which are now often referred to as critical intensive care outreach. My team was based at the Middlesex Hospital—it now operates at UCH—and ensured the liaison between teams that is so important to patients. The period of transfer between intensive care and the ward is often difficult for patients. I commend those teams.

I have mentioned the elements that I believe led to my recovery and to the excellent health that I now enjoy because, like the noble Baroness, I fear that they may at this moment be under threat because of the spending programme that is being implemented. We keep hearing that the money for the NHS is ring fenced but, as a 0.1 per cent real-terms increase is nowhere near enough to keep pace with demand, I wonder how these services will continue. As the coalition has abandoned the one-week target for cancer test results, literally more people will die as a result of late diagnosis. That figure is currently estimated at 10,000 per year.

Much late diagnosis is due to patients not seeking treatment until it is too late, so I hope that the Minister can assure the House that the Government have no plans to scrap screening programmes or those promotional activities designed to ensure that people seek consultation. As a result of there being a possible hereditary element to the cancer that I had, my son and daughter also have regular colonoscopies. Will such services fall victim to the “must do more with less” mantra? Sadly, there are still too many people who find a possible diagnosis of cancer so frightening that they put off consulting a doctor until it is too late. I am sure that every one of your Lordships could name a friend who has ignored obvious symptoms such as weight loss, unexplained bleeding, coughs and so on. That is one reason why those of us who are fortunate enough to have recovered have an urgent responsibility to say so and to help remove the fear that gets in the way of seeking help.

I do not see how, in these hard financial times, we can possibly be thinking of spending £3 billion on an NHS reorganisation, which few seem to want, without it further affecting the services that are so vital to early diagnosis. Moreover, I fear that giving the bulk of the resources to GP consortia will run counter to the liaison between hospital and locally based services, which proved so helpful to me. GPs will have to decide whether treatments are necessary, affordable and the cheapest option, but the care will be in the hands of the hospital consultant. How is that likely to benefit the patient? At the very least, it seems to provide much opportunity for delay and little encouragement for the integrated services that cancer patients often need. We must be wary, too, about GP consortia becoming so overloaded with their commissioning functions that they cease to have as much interest as they should in promoting lifestyle changes, such as smoking clinics and exercise clubs, which are so important in the prevention of cancer.

I finish with a plea to remember the families and carers of those with cancer. They, too, need to be involved in the process and fully informed, as they will often provide the bulk of the care. I know that confidentiality of information is an issue, but that can usually be resolved. If families do not know, they cannot help. Cancer affects the whole family and we need to remember that.