Care Services: Winterbourne View

Baroness Wall of New Barnet Excerpts

Monday 10th December 2012 Lords Chamber

[Baroness Wall of New Barnet]

My Lords, I also congratulate the Minister on repeating this Statement made earlier in the other place, and I welcome the report itself. I want to refer to a couple of areas and follow up his reassurance about the patient care pathway. The importance of that pathway, I am sure he knows, is not only in having it but ensuring that it is carried out with regular updates, and that the progress being made is taken into account to make sure the pathway is staying in touch. That does not always happen, so having the patient care pathway is only one part of what I hope he would ensure would happen.

The other part, and the Minister may not be surprised at this, is Part 7 where again, as my noble friend Lord Hunt has done, I urge him to think again about another area. With regard to the expectation as far as training goes—while Skills for Health and Skills for Care, as mentioned in the document, are doing a great job—it is absolutely crucial to recognise that just the induction for health care assistants in social care really is not enough. I have pleaded with the Minister on many occasions in the context of hospitals. It is equally if not more important that healthcare assistants have the confidence given to them by being registered and qualified in the way that registration ensures, so that the very difficult and important job that they do—and more of them are doing it than are working in any other area—is suitably recognised. I urge the Minister to take away that request in the context of this report, and to look again at ensuring registration for these particularly important workers.

[Earl Howe]

My Lords, I am grateful to the noble Baroness for what she has said. She is right to point out that the patient pathway is integral to any proper planning process for individuals, and that it should be built around the particular individual’s needs and preferences if possible. This brings us back to the role of an assessment and treatment centre: namely, as its name implies, to assess the needs of a person and to define what their care plan should be over a future period of time. As I mentioned, the care plan is best when it is drawn up with the benefit of advice from the individual, their family and their carers. Therefore, if we want more community care, we need to ensure that there is the capacity in the community to deliver good patient pathways to individuals. We are clear that some areas of the country are ill equipped to do that. Part of the task of the joint improvement programme will be to look at the facilities and resources that are required in local areas to enable commissioners to plan those patient pathways with confidence.

On the issue of the training of care assistants, I take the noble Baroness’s point. I think that it is common ground between us that those who lack a recognised qualification should nevertheless be enabled to upskill themselves and get themselves on a register to prove that they are familiar with and abiding by a code of conduct that has been recognised, with the register itself being duly accredited. Our position is that the system of voluntary registration, almost by definition, will result in an upskilling of the workforce, but it is not the whole story. There is a role for employers to ensure that there is proper supervision of care assistants, and that proper delegation takes place that does not require a person to do more than he or she is skilled to do. There is no single answer here, but I believe that voluntary registration is a good start.

NHS: Liverpool Care Pathway Inquiry

Baroness Wall of New Barnet Excerpts

Monday 5th November 2012 Lords Chamber

[Earl Howe]

My Lords, I fully agree with the noble Lord. Training is integral to the care pathway, as is the need to consult the families of patients and, if possible, the patients themselves before a decision is taken to put them on the Liverpool Care Pathway. On the NHS constitution, I completely take the noble Lord’s point. The proposed change to the NHS constitution makes it absolutely clear that patients and their families and carers have the right to be fully involved in discussions and decisions about their care, including that at the end of life. We are clear that that should already be happening, but we understand from reports that that is not always the case. As regards end-of-life care, I think there is sometimes a taboo on discussing death and dying and press reports show how damaging that can be. I shall indeed take all the noble Lord’s points on board, particularly as regards nutrition and hydration.

[Baroness Wall of New Barnet]

My Lords, I am relieved by the Minister’s response to the noble Baroness, Lady Knight. He is absolutely right that the care people receive at the end of their lives is hugely important. National statistics show that 29% of eligible people are on the care pathway. In my own trust, Barnet and Chase Farm, 28% of people are currently on it. The involvement of carers in those discussions is huge and a whole protocol is attached. I, too, am extremely worried about the publicity, some of which I am sure is well meant, but it can be very damaging to a system that provides a great deal of care. My mother-in-law was on the Liverpool Care Pathway in Liverpool hospital and had a very good experience. Please can we ensure that in any discussions we look at the overall benefit to elderly people at the end of their lives?

[Earl Howe]

The noble Baroness is quite right. So often, good experiences are not reported. Predominantly we hear from patient organisations and the Marie Curie organisation that in the vast majority of instances where the Liverpool Care Pathway has been used, it has resulted in better care for the dying person. She is absolutely right. Nevertheless, where the pathway is not being properly followed, we have to take the matter seriously and ensure that there is proper training and communication with care staff.

NHS: Accident and Emergency Services

Baroness Wall of New Barnet Excerpts

Tuesday 23rd October 2012 Lords Chamber

[Earl Howe]

My Lords, I agree with the noble Baroness. That is exactly why the Government are planning to roll out the 111 service, which will run alongside the 999 service for emergency calls. But where the situation falls short of an emergency, the 111 service will instantly direct the patient to exactly the right service, without a call back being necessary. I am pleased to say that that programme is on track and should be rolled out next year.

[Baroness Wall of New Barnet]

My Lords, I declare an interest in Barnet and Chase Farm, which is currently being restructured. Does the Minister agree that, with any restructuring of services in the health service, the public are very concerned? A lot of effort is being made by the trust to assure people, but one of the things that keeps coming back—certainly for Barnet and Enfield—is that the bus services do not always work in the way in which the noble Earl has suggested, and that Transport for London is not always co-operative. Very often it is, but sometimes it is not; we are having a great deal of difficulty reorganising bus services in cases where Transport for London will just not hear of it.

[Earl Howe]

My Lords, in north London and Barnet in particular, Transport for London has diverted the 307 bus route into the grounds of Barnet Hospital, thus improving the link from Enfield. Transport for London has also installed new CCTV cameras in the underpass at North Middlesex University Hospital, in order to enhance its safety. There was a proposal to improve the local underpass at Silver Street station, and that was carried through. I am concerned to hear the noble Baroness’s perception, because all the briefing I have had indicates that Transport for London is very constructive in these situations and will often change bus routes in response to changes in service configuration.

NHS: Evidence-based Medicine

Baroness Wall of New Barnet Excerpts

Wednesday 10th October 2012 Lords Chamber

[Earl Howe]

My Lords, yes I can. There is a real impetus within Government to look at evidence-based treatment for illegal drug users.

[Baroness Wall of New Barnet]

My Lords, I am surprised that in his response to the noble Lord, Lord Taverne, the noble Earl did not remind him of the health and well-being boards which make decisions now about what is happening locally. Certainly, from my experience, homeopathy has been one of the issues that the health and well-being board in Enfield has been looking at. Obviously, the evidence base is important, but should not that direction on what is locally required be made a priority?

[Earl Howe]

The noble Baroness makes an important point, and of course she is right that health and well-being boards will be very important forums for establishing the clinical priorities in geographic regions and then setting strategies to meet those priorities. However, in the end, it is for commissioners and individual clinicians to decide what is best for patients in a particular area.

NHS: Private Finance Initiative Costs

Baroness Wall of New Barnet Excerpts

Wednesday 11th July 2012 Lords Chamber

[Earl Howe]

The noble and right reverend Lord is right. We believe that a number of the PFI schemes from the previous Administration were not soundly based in terms of their sustainability. As part of the work that we are doing on the Foundation Trust Pipeline, we have had to work on long-term sustainability solutions to help NHS trusts with PFI schemes, hence the direct financial support that I have referred to.

We have also organised PFI trust forums to disseminate the lessons learnt and to share experiences. We have earmarked resources to support the front line in ways to secure savings and we are currently in negotiation with people who have experience in the NHS and private sector to form a new team to support existing contract managers and, where necessary, to support negotiations with private sector PFI companies.

[Baroness Wall of New Barnet]

Will the noble Earl agree that in addition to the detriment suffered financially by PFI hospitals, as the noble and right reverend Lord Harries described, they suffer from a stranglehold as regards the movement of services, which means that they have to hold services back? Is not such power to stop the increased movement of services preventing trusts modernising and developing?

[Earl Howe]

The noble Baroness makes an important point and it is one that I was aware of some years ago when I visited a PFI-funded hospital. She is right; it does sometimes depend on the relationship established between the contractor and the hospital management but many of these contracts do result in exactly the kind of sclerosis that she has described. It is a lesson that we need to learn for future PFI schemes.

NHS: Annual Report and Care Objectives

Baroness Wall of New Barnet Excerpts

Wednesday 4th July 2012 Lords Chamber

[Earl Howe]

As so often, my noble friend has alighted on a real issue and I am grateful to her. She is right that we are not seeing enough trainee doctors going into general practice. The previous Government and we have had informal targets for new GPs. We have not met those targets for a few years now. It is a matter of concern and we are working very closely with the universities, the Royal College of GPs and others to see how the numbers can be rectified. It is not just a numbers game because, as she rightly alluded to, we should increasingly be seeing a better sharing-out of responsibilities in the community between not only GPs but community nurses, practice nurses, midwives, health visitors and others. There is quite a lot of work to be done there.

My noble friend is right about women GPs, and headcount numbers in that context are not always the most reliable indicator of the workforce number. This is part of the reason why we set up Health Education England, because with the advice of the Centre for Workforce Intelligence, the body that advises the Government on long-range forecasts of workforce needs, and the input from local providers—primary care providers, not just hospitals—of what they see as their needs into the future, we ought to get a much better handle on long-term needs for the different professional disciplines.

I do not at all brush aside this problem. I hope my noble friend realises that this is a real issue and we are grappling with it. Actually the NHS has grappled with it for a number of years, partly unsuccessfully, but we hope to do better with the new configuration that we have debated so often.

[Baroness Wall of New Barnet]

My Lords, I welcome the report and in particular I thank the noble Earl for his emphasis—which I would like him to re-emphasise when he responds—on just how hard people are working in the NHS. As always, I reflect my own experience. I do not live in a different world from other people and I certainly know from the trust that I am chair of that people are working exceedingly hard.

Although there are some reservations, if I may say so to the noble Earl, around the progress we are having, I think that that is more about people getting used to what the changes mean. In particular, I want to focus on the CCGs. As the noble Earl knows, my trust has a hospital in Barnet and one in Enfield. Barnet CCG is firing away and working brilliantly. Enfield is still trying very hard to get its act together. The noble Earl knows how much I care about this, and the effect is that we are not getting the primary care out in Enfield where we need it. I would have liked the report to have focused more on moving away from hospitals—which I know is supposed to be heresy for someone who is the chair of a provider trust, but I really believe this—and making sure that we have the opportunity for more primary healthcare and support for those CCGs to be urged forward.

I know we have only a minute so I am not going to say anything else because I know other colleagues have been waiting desperately to get in, but there is a lot more I could say.

[Earl Howe]

The short answer to the noble Baroness is that she is, of course, absolutely right about service redesign locally. It involves the kinds of conversations that are already happening in many areas between primary and secondary care clinicians to see how we can bring about that shift that most experts agree is desirable and certainly patients want to see. This is an ongoing conversation. I do not know as much as I should about the noble Baroness’s particular area of the country, but I will gladly follow that up with her after this.

Care Quality Commission (Registration and Membership) (Amendment) Regulations 2012

Baroness Wall of New Barnet Excerpts

Monday 25th June 2012 Grand Committee

[Baroness Jolly]

Certainly that was my experience. Although there were instances where we had uncomfortable inspections, afterwards an awful lot of work was put in to try to remedy issues that had been raised. The team went in as a team and worked as a team. Everyone on the team had experience of working within the NHS in one format or another and, although we may not have carried out identical roles to those that we were inspecting, there was a clear awareness that we knew what we were about. I shall not carry on at great length because of the time.

The amendments to the registration are a tidying-up exercise. All that we are doing is replacing the National Patient Safety Agency with the NHS Commissioning Board Authority, so it is a cut-and-paste job, if you like. Will the Minister confirm that in due course this will subsequently transfer to the board when the board becomes the board and not just the authority? Will the Minister clarify the situations where deaths and other incidents in these situations involving service users—vulnerable people—are reported and say why they might be reported to the board and not to the CQC? If we are to learn anything from this information, it is critical that the board commits to publishing it on a regular basis. It also needs to be part of the board’s regular agenda.

On a related issue, will the Minister update the Committee on deaths of service users and untoward incidents, which cause difficulty for carers and, in the case of untoward incidents, the patients themselves? During the consideration of the 2012 Bill, there was much debate about the duty of candour. Will the Minister give us some sort of update on where things are? I remind him of his comment on 27 February:

“I reiterate the commitment that I have given today that the Government intend to use the ‘standing rules’ regulations to specify that the contractual duty of candour must be included in the NHS standard contract”.—[Official Report, 27/2/12; col. 1055.]

That was a welcome move but I would appreciate it if the Minister could update us on where we are. I appreciate that this will not happen overnight; it will require training and a large amount of cultural change.

I move on to the governance and board membership issue. Today we had the interesting interim report on the Winterbourne View Hospital. Bearing that in mind, will the Minister reflect on whether he believes that the new governance arrangements proposed in these regulations will minimise or even avoid a repetition of this level of behaviour or such an appalling lack of dignity for those with learning disabilities? Does he believe that adequate funding is available for the CQC? Again, the noble Lord, Lord Hunt, gave us a long list with numbers relating to its remit—it is really broad and deep. The Committee would probably feel comfortable if it felt that the CQC was being ably supported with adequate resources. It has had a difficult role in changing times and it can use its registration requirements to drive up quality. To that end, the Government must work with it. I think that we would all agree that service users and carers deserve no less.

[Baroness Wall of New Barnet]

My Lords, I, too, support my noble friend’s view of the CQC. I want to mention, as he has done, the work carried out by the previous chief executive and the chair of the CQC, and welcome the new chief executive. The noble Lord may remember that when we had a discussion in the House on the social services Bill about care in some care homes, he made a plea, in response to a question, that we should look at the CQC’s responsibilities and not blame the CQC itself for everything that happens. More and more, that is certainly my view.

I am not aware of any detail of the alternative ways that the noble Lord and the noble Baroness, Lady Jolly, have mentioned, but I am concerned about—my noble friend raised this issue—the credibility of the CQC. I have noticed from my experience in the trust that the more responsibilities the CQC has been given, the greater the perception that it is going to be very thinly spread and that its expertise will in some way be weakened. That may be people’s view rather than the reality, but I think that we owe it to everyone who has a relationship with the CQC not to dilute it by continually adding to its responsibilities. I know from my own experience how important its inspections are, certainly in hospitals.

The noble Lord referred to my trust, which covers a two-district general hospital, and also to some very small GP practices and other areas of work. I am a great supporter of the CQC, as the noble Lord will know. I feel that it has done a tremendous job and has made a difference compared with what happened before it came into being. I want to strengthen that rather than in any way to dilute its reputation. For example, people who work in my hospital say, “My goodness, it’s doing everything now”, but what does that really mean? I am sure that the noble Earl will have listened to everything that has been said and that he will think very carefully about what the CQC’s credibility means to all of us in terms of its responsibilities.

Health and Social Care Bill

Baroness Wall of New Barnet Excerpts

Tuesday 13th March 2012 Lords Chamber

[Baroness Wall of New Barnet]

My Lords, first, I apologise for missing the first five minutes of the noble Baroness, Lady Emerson, moving the amendment. With the House’s permission, I shall briefly speak to the issues that she raised, to which I have referred in the House on many occasions, as many noble Lords and certainly the Minister will be aware.

I understand the arguments that have been made by my noble friend, but healthcare assistants—and they are mostly in clinical areas—have a strong desire to be recognised and accredited for the work that they do. They take a pride in what they do, as the noble Baroness, Lady Emerton, said, but patients do not understand what they do and therefore cannot have the discussion with them that says, “You are qualified, so I have confidence in you”.

I have had this discussion with the Minister on a number of occasions, and I am not sure why there is hesitancy in this area. I do not think there is an issue for trusts in being able to get healthcare workers who are qualified. We have a sector skills council for health, most of whose work is encouraging healthcare assistants and other people who work in hospitals to reach levels 1 and 2, so there is an equivalent provider out there that can do that, working with the hospitals.

The important thing is that the patient understands exactly what the healthcare worker does. The amendment of the noble Baroness, Lady Emerton, describes a healthcare support worker as an individual whose work is “routinely delegated to them”. That is crucial. It is not someone who does something off their own bat. My hospital employs many hundreds of healthcare workers, most of whom do a very good job. It is very important that the noble Earl knows that they are very conscientious when working with other practitioners, clinical or otherwise, who do not do what they are supposed to do. We have many healthcare workers who check that consultants’ arms are bare to the elbow. They are very conscientious and they want recognition that they are people who care about patients. They want to know that the value that they bring is recognised. It is no threat to the health service; speaking as a provider chair, I can say that it is a total advantage.

[Baroness Masham of Ilton]

My Lords, we are once more discussing the important matter of the power to regulate healthcare support workers in England. I am pleased to have added my name to the amendment. I spoke about this at Second Reading and in Committee. I agree with the Royal College of Nursing that mandatory regulation and registration of these support workers is important in order to safeguard patients’ safety and to ensure standardised training so that there is a skilled and suitable workforce.

I have yet to meet anyone who understands the situation who disagrees about this, except some members of the Government. Nurses who have been struck off their register can then work as care assistants—again, putting patients at risk. The Government are considering a voluntary register, but this will not cover the undesirable people who get jobs as care assistants because they cannot get employment elsewhere. Clinical physiologists have found that self-regulation, which they have had since 2001, is not as effective as statutory regulation. Should we not learn from this?

We know of the tragic cases at the Mid Staffordshire NHS Foundation Trust, where the deaths of hundreds of patients were associated with bad care. It makes one wonder how Mid Staffs was approved for foundation status. We also know of the horrific bullying by care assistants at Winterbourne View care home at Bristol. Since Committee, we have heard of Malcolm Cramp, who was convicted of seven counts of ill treatment and sent to prison for abusing dementia patients at Brockshill Woodlands, a care home in Leicestershire. In another case, Sean Abbott, a caseworker, was jailed for a year for assaulting vulnerable residents at St Michael’s View care home in South Shields. Daphne Joseph, another person at that home, was given a nine-month suspended sentence when she admitted the ill treatment and neglect of a patient, who died. The judge at Newcastle said that she had not had enough training. He also said that she was operating,

“in a regime which was inadequate and not fit for purpose and in which there were too many patients, not enough planning, and too few staff, let alone trained staff”.

This concerning situation is happening up and down the country. Is it not time that better safeguards for patient safety were put in place? Statutory regulation and the registration of healthcare workers could help. Many of them are now undertaking procedures that only doctors and nurses did but they have little training to do it.

--- Later in debate ---

[Earl Howe]

The key here lies in the standards and the training. If we have standards laid down that are uniform across the piece, I am not sure that having more than one register is a significant issue. As I said, this is something that the professional standards authority is bound to take account of when deciding whether to accredit another register.

The noble Lord, Lord MacKenzie, expressed the view that voluntary registration does not work. The Government’s proposals are for assured voluntary registration. We believe that the effective assurance of the standards of healthcare support workers can be delivered by an assured voluntary register that is underpinned by clear standards of conduct and training and supported by the Nursing and Midwifery Council’s updated guidance on delegation.

The noble Baroness, Lady Finlay, asked how standards will be monitored. We will expect the professional standards authority to assure that any standards set for a voluntary register are appropriate as part of its initial accreditation process. It will keep the operation of any register under review and we will expect it to set out any concerns that it has about standards. The authority will also have powers to remove the accreditation of registers if any of its concerns are not addressed in a timely fashion.

The noble Lord, Lord Patel, asked what criteria would apply in individual cases. In its council paper, Voluntary Registers—Proposed Model for the Accreditation Scheme, the CHRE has stated that all voluntary registers seeking accreditation will be required to complete a risk assessment tool that will assess the risks inherent in a profession’s practice and the means by which those risks are and could be managed. The authority will also keep under review the management of risks by an accredited register. That will be part of its role.

However, having listened to the concerns raised in this House, the Government have given further consideration to this whole issue. Once a system of assured voluntary registration has been established for this group and has been operational for three years, to enable it to demonstrate its effectiveness the Government will commission a strategic review of the relative benefits of assured voluntary registration compared with statutory regulation. The review will involve all relevant professional bodies and trade unions. Such a review would include consideration of any further measures needed to assure the safety of patients and the public, including consideration of the case for compulsory statutory regulation or—and I say this in particular to the noble Lords, Lord Kakkar and Lord Hunt—making standards of training mandatory for employers through the use of standing rules for the NHS Commissioning Board and standard contracts for providers.

The noble Lord, Lord Kakkar, raised what I thought was a very astute point about the NHS standard contract. I can confirm that, yes, the Secretary of State will have the power to include in the standard contract the fact that relevant workers must be on a particular voluntary register. We see this as a strong lever, and we would want to consider it very carefully before deciding to use it in a particular instance, but wherever there was clear and demonstrable evidence that doing so would ensure quality of care, we would give it very serious consideration.

I can confirm that the question of whether to move to statutory regulation will be viewed openly, with full consideration of the potential benefits that it might be able to bring. I can say to my noble friend Lord Newton once again that the power to introduce statutory regulation already exists, in Section 60 of the Health Act, if a decision were to be made to deploy it. The Law Commission is in fact consulting at the moment on an even broader regulation-making power in the future. In the mean time, we are committed to exploring the evidence base on ratios of qualified to non-qualified staff. I totally agree with the noble Baroness that this is a key point. We will look carefully at the evidence from ongoing work by King’s College.

I have tried to set out what one might term, picking up a phrase from the noble Lord, Lord Patel, the direction of travel here. I hope that the noble Baroness, Lady Emerton, will understand our commitment to seeing defined standards and improved skills in the healthcare support workforce. The noble Baroness, Lady Masham, asked whether it is not time to have better safeguards in place. Yes, it is. I agree with her. Where we part company is on what a set of new safeguards should be. I strongly feel that a combination of voluntary registration and training is the more appropriate and proportionate solution to what I agree is a problem that needs to be addressed. The work that we have commissioned takes us on that road.

I hope that I have been able to reassure noble Lords of our commitment to strengthening the assurance processes in place for health and social care support workers, and that, perhaps with reservations but nevertheless more confidently than before, the noble Baroness—

[Baroness Wall of New Barnet]

I have listened carefully to what the noble Earl has said and there are two areas that he has hardly mentioned—indeed, he has not mentioned one at all—but which he should perhaps refer to. What consideration has he given to the fact that, if you talk to healthcare assistants—and I mean literally hundreds of them—you find that they want this qualification and registration to illustrate the value that they have not just to themselves but also to colleagues around their hospitals? This is also the case for patients: if you do any survey of patients, they say that they want healthcare workers to be registered, so that they understand and have the assurance of that. I wonder how much consideration of those factors has gone into the deliberations that he is talking about.

[Earl Howe]

I apologise to the noble Baroness for not covering that point. We are well aware of precisely that view among the workforce. With the creation of a voluntary register, the process that she refers to will gather its own momentum because people will see the opportunities open to them to accord themselves the status that they clearly crave. It is important, from the point of view of the patient, that hospitals—and, indeed, care homes—are employing people of a certain standard of accreditation and skill. I think, therefore, that this will be self-fuelling and I hope that, once the register is on offer, substantial numbers of healthcare support workers will be encouraged to join it.

Health and Social Care Bill

Baroness Wall of New Barnet Excerpts

Thursday 8th March 2012 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, we have, I hope, threaded education and training through the Bill and established it as a core principle for all providers.

In support of the comments by the noble Lord, Lord Turnberg, it is essential to place on record that the vast majority of specialist training for all those specialties in secondary care occurs in those places that will have foundation trust status, if they do not have it already. That future investment in the specialist workforce to provide services is essential and there is merit in restating the importance of it.

[Baroness Wall of New Barnet]

My Lords, I also support the amendment. Adding to what the noble Baroness, Lady Finlay, has said, the House may be aware that trusts are now committed to quality accounts, certainly for clinical staff, and an integral part of those quality accounts is education and training. I would like to see it being widened beyond the clinical staff, because there are lots of staff in a hospital who need that constant education and training, to make sure that patient care overall is as good as we would all want it to be.

[Lord Hunt of Kings Heath]

My Lords, I refer to my chairmanship of a foundation trust. From the opposition Benches, we very much support this amendment and wish to reinforce the importance of education and training.

It is right that we should emphasise the importance of NHS foundation trusts recognising their responsibilities in relation to education and training. It is equally important that they have an influence over the architecture for education and training. As the noble Earl will know, there are going to be local boards responsible for commissioning the education and training of professional people. It is very important that the people who run hospitals should be very much involved in the selection of students and ensuring that the curriculum is effective. The noble Earl will know that the Future Forum paper chaired by the chief executive of University Hospitals Birmingham NHS Foundation Trust emphasised the importance of looking at these matters.

We will be debating the quality of nursing next week, but there is no doubt that there is a real problem with public perception of the quality of nursing in particular, and issues to do with nutrition and basic nursing skills. I am convinced that there is a real problem that the universities that train our nurses, in the end, are much more focused on academic practice, because that is what universities do. I am anxious that no one has been able to put their finger on the solution. One way of improving the quality is to involve the foundation trusts much more in these matters. My noble friend’s amendment is very helpful in that respect.

Health and Social Care Bill

Baroness Wall of New Barnet Excerpts

Tuesday 6th March 2012 Lords Chamber

[Lord Turnberg]

I shall speak in support of Amendment 165 in the name of the noble Baroness, Lady Finlay of Llandaff. This amendment is designed to ensure that Monitor encourages integration and collaboration. In all that, it is important that Monitor ensures that the operation of the system of payment by tariffs does not interfere with that integration and, at worse, adds to the costs of the health service.

I shall give two examples of where the tariff system might be counterproductive. The first is in relation to the hospital admission of a patient who goes home, is readmitted and may be readmitted several times. It is in the hospital’s financial interest to have these episodes of care because it gets paid by the tariff each time the patient comes in. There is no inducement in the hospital to try to enlist social services. I am sure that it does, but the system works against that and tends to promote readmission as a way of earning money.

The second concerns patients who are in the hospital for one condition and develop a condition relevant to another consultant. For example, a patient may come in with an orthopaedic problem such as a broken hip, and then develop an acute episode of diabetes, so there is a need to call for a diabetologist to look after the patient’s diabetes. That requires a rather tortuous consultation process which involves a second episode and a further payment by the tariff system. Those are two obvious and common examples of where integration is interfered with by the system we are operating.

I know that the Government are not keen to change that sort of system, but there must be ways for Monitor to look at it critically and see whether the current tariff system can be made to work better than it does at the moment. I hope that the noble Earl will be able to comment on that.

[Baroness Wall of New Barnet]

Perhaps I may contribute to the debate solely on the comments that have just been made by my noble friend. As regards the first instance he mentioned, that is no longer the case. If someone is brought back into hospital with the same disease or illness, no tariff is paid. As far as I am concerned, that is certainly the guidance we have had from the Department of Health and it is being applied. It is still the case with regard to the second example— I guess quite rightly. But from my experience as the chair of a foundation trust—my noble friend Lord Hunt is nodding in agreement—if someone is admitted again with the same illness there is a presumption that they were not dealt with properly in the first place. As a result, the treatment has to be carried out under the first tariff and no additional tariff is granted.

[Lord Turnberg]

My Lords, I wonder whether I could comment on that. It depends on the timescale between admissions. If it is longer than two months, I think that you get a second shot.