Mental Capacity (Amendment) Bill [HL]

Baroness Watkins of Tavistock Excerpts

Report: 2nd sitting (Hansard): House of Lords
Tuesday 27th November 2018 Lords Chamber

Moved by

[Baroness Watkins of Tavistock]

29: Schedule 1, page 10, line 8, at end insert—
“Rights to information11A(1) Prior to the authorisation process, the cared-for person must be fully informed of their rights.(2) The responsible body must take such steps as are practicable to ensure that the cared-for person and any appropriate person or Independent Mental Capacity Advocate representing and supporting them understand the possible outcome of the assessments, the reasons why the cared-for person may be deprived of their liberty and their rights—(a) to request an Approved Mental Capacity Professional’s assessment and review of the arrangements,(b) to advocacy, and(c) to challenge the authorisation in court.(3) If an Independent Mental Capacity Advocate is appointed under Part 5, the advocate is to take such steps as are practicable to help the cared-for person and the appropriate person to understand the following matters—(a) the steps involved in the authorisation process,(b) the purpose, duration and effect of the authorisation,(c) any conditions to which the authorisation is subject,(d) the reasons why the cared-for person met the qualifying requirements in question,(e) the right to object to the authorisation and the right to request a review by an Approved Mental Capacity Professional,(f) the outcome of a review of the arrangements,(g) the relevant rights of the cared-for person,(h) how the cared-for person may exercise relevant rights.(4) In this paragraph, “relevant rights” includes the right to make an application to the court to challenge an authorisation decision in court under section 21ZA and the right to request a review of the arrangements.(5) The responsible body must ensure that cases are referred to court when the cared-for person’s right to a court review is engaged.”

[Baroness Watkins of Tavistock (CB)]

In moving Amendment 29, I shall speak also to Amendment 86, having added my name to both. My noble friend Lady Hollins originally tabled this amendment, which is associated with rights to information. She is unfortunately unable to be here, so in her absence I will articulate the points on behalf of us both, without repeating many of the arguments made at Second Reading. The amendments are supported by many third sector bodies, including the Royal Mencap Society, Mind, Rethink Mental Illness, the Alzheimer’s Society, Disability Rights UK, Inclusion London, Liberty, VoiceAbility, the National Autistic Society, Sense and others.

As it stands, there is a fundamental imbalance in the proposals, with the power in many cases lying with health and social care providers and the responsible body. These amendments seek to partially redress that balance, in part by ensuring that critical information is provided to the individual concerned, the person being cared for, and those advocating on their behalf.

Under the first part of Amendment 29, the individual would receive information about their rights in advance. This is critical, as is having someone—an appropriate person or advocate—to explain things to the person in a way meaningful to them. VoiceAbility, which provides advocacy for people who may lack capacity and their families, has received feedback from families that having information clearly explained to them up front can help dispel many misunderstandings and myths that can escalate to the person being cared for being very unsettled.

Knowing the reasons why you were detained, and what you can do about it if you are not happy with your conditions or placement, is important. Similarly, the knowledge that you can ask for a review or challenge the decision can help to reduce the stress and anxiety that many people face—even if the person does not at the outset wish to exercise their rights to review or challenge.

Information should, of course, be provided in an appropriate format, which is clear, easy to understand and takes account of any communication difficulties that individuals or their families have. Providing people with just written information is not enough. Some people may require easy-read information in jargon-free, plain English. Others should have the opportunity to speak to somebody and ask questions. Some families may need a translator, and some individuals may need sign language such as Makaton to fully understand the situation they find themselves in. There is very limited knowledge about DoLS and even less about the proposed LPS, and it is therefore critical that people understand the process they are entering.

The Bill requires the responsible body to complete an authorisation record containing important information for the cared-for person. It does not, however, require that this information be automatically provided to the cared-for person, their family or an advocate. The second part of Amendment 29 and Amendment 86 address this by ensuring that the responsible body provides the cared-for person and any advocate with information about the outcome of the authorisation, what it means and the reasons why their liberty may be deprived. As before, this must be provided in a format that is appropriate for them and easy to understand. It must also detail the person’s rights to challenge the assessment and request an intervention from an approved mental capacity professional, their right to advocacy and how to challenge the authorisation should they so wish. People often feel disempowered in this situation, and in many cases simply accept inappropriate provision without understanding that they can challenge it. Finally, these amendments would ensure that information is provided relevant to the process of how to challenge their individual assessment and, in turn, the fact that their liberty is being deprived.

Advocacy must play a central role in this Bill. The amendment recognises this by spelling out the functions of an IMCA at this critical juncture for the cared-for person. This includes helping the individual to understand the process, the assessment itself and the result of that assessment, as well as how they can exercise their rights of challenge.

I hope the Minister recognises that these amendments are an important addition to ensuring that people are empowered throughout the process. I look forward to his response. I beg to move.

--- Later in debate ---

[Lord O’Shaughnessy]

I recognise the point that the noble Baroness is making. As I said, our belief is that the rights that currently exist, and are in no way amended or reduced as a result of the Bill, provide what she is asking for. Unfortunately, I am not able to give a commitment that we will be able to return to this issue at Third Reading.

[Baroness Watkins of Tavistock]

I thank the Minster for his reply and thank all noble Lords who have spoken in support of this group of amendments. I do not believe that the Minister’s reply gives us sufficient security that if the information is contained only in the associated code patients and their families will be protected in the way that we have outlined. We firmly believe that the issue of information and, in particular, its provision in advance need to be in the Bill. It is therefore important that the House makes a statement to the Government about this issue, so I would like to test the opinion of the House.

Mental Capacity (Amendment) Bill [HL]

Baroness Watkins of Tavistock Excerpts

Report: 1st sitting: House of Lords
Wednesday 21st November 2018 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, I support this group of amendments. One or two offer a slightly different definition or slightly different words but the key point for me, having moved a similar amendment in Committee, is that we have now removed the phrase “unsound mind” from the Bill. I know this is welcomed here and will be hugely welcomed by many in the sector. It means we will get rid not only of a very old-fashioned and stigmatising term but one on which there were also concerns—as I understood from my conversations with the Royal College of Psychiatrists—that it had no real clinical meaning. The term “mental disorder”—or the few more words added by other amendments—not only brings us in line with the Mental Health Act, which is good, but I am advised that it will also help to provide diagnostic clarity. That has to be a good thing too. I support this group of amendments.

[Baroness Watkins of Tavistock (CB)]

My Lords, I support this group of amendments and I am delighted that the Minister has had his mind changed. Not using this phrase will change how people feel about their relatives who may be suffering from mental disorders. I am also optimistic that, in the longer term, using such modern nomenclature will make mental health professions more attractive to young people.

[Baroness Finlay of Llandaff]

My Lords, I also welcome these amendments; removing “unsound mind” is a major step forward. I have a couple of questions for the Minister and I hope he can clarify. I may have misheard him but I understood him to talk about head injury. It would be helpful if he could clarify that he was referring to acute head injury—or acute brain impairment of any sort—as opposed to long-term damage such as frontal-lobe damage, which can happen when you have had a major brain injury. This can result in very long-term problems and difficult behaviours, which may mean that people currently need to be assessed as subject to deprivation of liberty. Could he clarify that we are not discounting a whole group of people who, it is generally felt, benefit from being properly assessed and safeguarded?

I would also like confirmation from him on another group. In January 2015, the then Mental Capacity Act deprivation of liberty safeguards policy lead in the Department of Health wrote out quite widely. There had been a concern about people who were nearing the end of life, including palliative care patients and patients in hospices. It was made clear in this letter that if somebody had consented to a care package and then went on—as part of their disease process when they were dying—to need some restrictions, and possibly to be moved to another place of care, that would not fulfil the acid test as such; neither would it in the case of people who were being nursed in a side room who were not under continuous supervision and control. The reason was that, in palliative care cases, there is often a time when the family cannot cope as the patient becomes unconscious, is moved to a hospice or develops another condition that had not been anticipated. It would be an inadvertent consequence if this letter from January 2015 no longer stood. It has been important and has made care easier. It was following this letter that we were able to change the regulations for what had to be referred to a coroner. That made a major difference, because families found it terribly traumatic to find a relative subject to a deprivation of liberty safeguard having to be referred to a coroner. I simply seek clarification on those two issues, but I in no way question the importance of removing “unsound mind” from the Bill. I hope this is the beginning of us seeing the end of that term, which is stigmatising.

Child and Adolescent Mental Health Services

Baroness Watkins of Tavistock Excerpts

Wednesday 24th October 2018 Lords Chamber

[Lord O'Shaughnessy]

I certainly think that is an interesting idea which I am very happy to feed into that process. I know the noble Baroness is a great campaigner on this issue, and the numbers of young people who are suffering from mental health problems are, frankly, terrifying. On the point about access, she was right that around one in four children and young people have been able to access these services. Our ambition, which we are on track to meet, is that this should rise to 35%. Clearly, we ought to reach 100%, but that involves recruiting a very large workforce, which we are in the process of doing.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister comment on whether there will be significant investment in trying to take psychology graduates into mental health nursing to enhance the number of people entering the profession?

[Lord O’Shaughnessy]

I do not know the specifics on psychology graduates; I will write to the noble Baroness. If the number of nurses in mental health nurse training at the moment comes through into the profession, there will be 8,000 more mental health nurses by 2020. I am sure we will be keen to recruit them from wherever we can.

Mental Capacity (Amendment) Bill [HL]

Baroness Watkins of Tavistock Excerpts

Committee: 3rd sitting - (Hansard): House of Lords
Monday 22nd October 2018 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

It strikes me that Amendment 87E would apply not only to this Bill but to other Acts. Does it fit here? I understand the principle of what my noble friend is saying.

[Baroness Finlay of Llandaff]

It could have wide-reaching consequences, but a lot of people who have lost capacity and are in a state of high dependency are already in nursing homes, so they are already being cared for in the system and may be subject to deprivation of liberty. Some of them have long-term continuing funding for their care, but they have been there for a long time and the donee, who is managing all their affairs and advocating on their behalf, is very concerned about their welfare in the event of them failing.

--- Later in debate ---

We must therefore be very specific in view of the fact that these cases are rising, where private and public care providers are telling families what they cannot do. We must guard against this by making it clear in the Bill that it should not apply to domestic settings where normal arrangements are being put in place. We need the sort of arrangements that my noble friend Lady Meacher talked about for those few cases, but we have to restrict it to a few cases under very specific circumstances if we are going to have any domestic arrangements challenged in this way.

[Baroness Watkins of Tavistock]

My Lords, I support the amendment in the name of my noble friend Lady Meacher and the comments that my noble friend Lady Murphy just made. She said that she can speak only for the 900,000 people in this country with dementia—but that is a high proportion. I want to share with noble Lords that everything she said I agree with, as part of a multidisciplinary team but also because over 20 years ago she was my external examiner for my PhD—and I passed. The subject was about supporting people with dementia in the community, so this is close to both our hearts.

I will add a little to this debate. I support the amendment for two reasons. First, at the very least we need to think again about the Bill’s application to individuals in domestic settings; and, secondly, we need to think carefully about how domestic care arrangements can be authorised under a liberty protection safeguard and oversight properly maintained over the period of care—which may be for many years, because I agree that things change over that period. One of the things that can happen is that carers who are very good when you first see them are at the end of their tether three years later and can no longer manage. That is why the Law Commission suggests that the LPS should be integrated into care planning arrangements—but that does require regular review.

It may be feasible to amend the Bill so that the LPS could apply with the safeguarding professions of the Care Act, as my noble friend Lady Meacher has already said. Certainly there is a need to ensure that those who lack capacity are safeguarded when they are being looked after in domestic settings, as, sadly, we know that in a very small minority of cases deprivation of liberty occurs through carers’ lack of knowledge of alternative methods to maintain safety, and in even rarer cases in fact becomes a form of abuse. However, the current Bill, if enacted with a zealous approach by professionals, could become a serious intrusion into families’ rights to provide individualised, possibly slightly idiosyncratic care for their relative, which may be fully consistent with how both parties wish to behave within the confines of their family unit and own home. I therefore hope that we will be able to work with the Minister, and the Bill team as appropriate, to improve the Bill to better balance the rights of people being cared for by relatives in their own home, without unwarranted intrusion into the way in which families support and care for relatives with limited mental capacity, while ensuring that deprivation of liberty is appropriate to safeguard the individual.

Mental Capacity (Amendment) Bill [HL]

Baroness Watkins of Tavistock Excerpts

Committee: 2nd sitting (Hansard - continued): House of Lords
Monday 15th October 2018 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I support this group of amendments in particular because many cared-for people can express their wishes in the ways people have said. I want to give your Lordships an example from when I was working as an in-reach mental health nurse into a range of homes for people with learning disabilities. There was a young man who was extremely happy in the home in which he had been placed because it was near his parents. They used to visit regularly and they used to be able to take him out together and accompany him, because he was not safe to be out unaccompanied. When his parents died he showed all the signs and symptoms that the noble Baroness, Lady Hollins, outlined, which the staff put down to the fact that he was distressed that his parents had died. Actually, that was in part true, but he was terribly sad that his sister could visit him only once a month because she lived 200 miles away. She was very willing to visit him more and to take him out accompanied but could not do that unless he changed his home and moved nearer to her.

This actually had a successful outcome, so it is not a depressing story, but Amendments 32 and 35 in particular would make it a duty for the care home in which such a resident was living to think again. This particular young man was a very high fee payer paid by the council because his needs were very complex. There was not much in it for the care home to arrange for his transfer because it would be quite difficult to fill the place at the same cost outside. I want to bring reality into the Committee in relation to these two amendments and explain why I am so supportive of us considering them in a positive vein.

[Lord Touhig (Lab)]

My Lords, the questions from the noble Baroness, Lady Barker, deserve an answer. I am sure that if the Minister cannot provide one tonight we will get one because she raised some very important points. The example that the noble Baroness, Lady Watkins of Tavistock, just gave gives us a practical idea of how these amendments might apply if they were part of the Bill.

Amendments 32 and 34 underpin the absolute need to discover the wishes and feelings of the cared-for person. Mencap summed it up pretty well in the briefing that it sent to noble Lords when it said that the views of the cared-for person should be at the heart of this clause. That point was made by my noble friend Lady Thornton during the debate on the first group of amendments today.

Putting the focus on ascertaining the wishes and, just as importantly, the feelings of the cared-for person is central to this, as is right and proper. I and others spoke about this at Second Reading and, frankly, we hope that the Government will respond positively to these proposals. Amendment 33 in the name of the noble Baroness, Lady Hollins, would address this by adding the cared-for person to the list of those who must be consulted, and Amendment 35 would ensure that views were sought on whether any less restrictive alternatives were available—all good sense.

When faced with legislation like the Bill and the issues it raises I often think, “If this Bill was about me, what would I want?” Most certainly I would want the protection and defence of my basic human rights that these amendments offer. Is this not something that every noble Lord in this House would want? If it is, we should ensure that it is there.

NHS: Staffing

Baroness Watkins of Tavistock Excerpts

Wednesday 10th October 2018 Lords Chamber

[Lord O'Shaughnessy]

I completely agree with the noble Baroness that we want to make them feel welcome. I use this opportunity to state again how much those staff are valued and how much we want them to stay here. What we are doing about it practically is making sure that we communicate with employers and provide the EU settlement scheme—indeed, health and social care workers will take part in the pilot, which will happen later this year. We are sending that message and providing that reassurance. I understand that there is anxiety out there, which is why we want to reassure people, but I am reassured by the fact that there are more people from the EU working in the NHS and CCGs today than there were two years ago.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister comment on whether he will consider abolishing the health immigration surcharge, which non-EU nurses must pay to access NHS care? It is stopping people coming to work here.

[Lord O'Shaughnessy]

The immigration surcharge, which applies to all people coming to work here from outside the EU, is about making sure that there is a fair contribution to the running costs of the NHS. That is a reasonable thing to do—it is what the public would expect us to do—but it is important to ensure that it is done in a fair and reasonable way, which represents the average costs incurred by people coming from outside the EU.

Mental Capacity (Amendment) Bill [HL]

Baroness Watkins of Tavistock Excerpts

Committee: 1st sitting (Hansard): House of Lords
Wednesday 5th September 2018 Lords Chamber

[Baroness Barker]

The Human Rights Act was in force when the Mental Capacity Act was being debated. During the passage of that Act we considered very carefully what language we should use. Is the Minister saying that we got that wrong, and have there been cases of people who have fallen into the gap? If so, how many are there, and can he give the evidence by which the Government arrived at the conclusion they have now?

[Baroness Watkins of Tavistock (CB)]

It might be complex to find the right nomenclature, but I heard the noble Baroness, Lady Tyler, say that this was a starter for 10. I cannot see why we have to regress to 1959 language in the Mental Health Act without further exploration of whether we could redefine the term about perhaps affecting the mind, to take in that very small minority of people with severe physical illness that occasionally affects the mind. We have worked so hard to destigmatise both learning disability and mental health that it seems very sad that we cannot work a bit harder at this point on this issue.

[Lord Cashman]

I want to reaffirm the point made by the noble and learned Lord, Lord Woolf. Surely it is not beyond the wit of drafters and our legal experts, when referring to the starter for 10 offered by the noble Baroness, Lady Tyler, to refer to the European Convention on Human Rights and the jurisprudence arising from the European Court of Human Rights? It seems to me that it is elegantly simple to take such an approach, reassuring the rights that relate to the “unsound mind” in relation to the new definition offered. I hope my intervention makes sense—it is not often best practice to speak on the hoof on such legal matters. I hope that noble Lords will forgive me if I have not made sense.

The NHS

Baroness Watkins of Tavistock Excerpts

Thursday 5th July 2018 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

I thank the noble Lord, Lord Darzi of Denham, for introducing this debate and for his excellent speech. I also thank the noble Baroness, Lady Verma, whose eloquence on social care and the need for investment in it I wholeheartedly support. I declare my interests as in the register, most specifically as a mental health nurse of some 40 years’ standing.

There is a clear case for further integration of physical and mental health and community and social care provision if we are to meet the needs of our citizens and promote healthy living and, where necessary, treatment intervention. I am involved with the social movement Nursing Now, working with policymakers and senior nurses from several continents.

In Africa, a phrase is used: “Health is made in the home and communities and hospitals are for repairs”. We need to adopt this approach in our communities to serve our citizens as cost-effectively as is feasible. We are celebrating our investment in 70 years of the NHS, which has resulted in people living longer and healthier lives. However, this has brought the challenges associated with many older people having several complex health and social needs, a situation that was not fully anticipated in 1948. The challenges facing our young people in terms of mental problems and the increasing prevalence of non-communicable diseases associated with lifestyle are resulting in higher demand for healthcare intervention.

The demands on the NHS will continue to rise unless we focus on public health policies that encourage citizens to become more responsible for their own health. With the access we all now have to digital data, why should we not be more responsible for our own health records and monitor our responses to exercise, diet and medication? If our citizens are to be more accountable for their own health and well-being, they will still need health education, support and guidance to do so. Families need help in the early years of their children’s lives through effective health visitor interventions combined, where necessary, with structured support from social services and mental health interventions for families with experience of anxiety, depression or severe and enduring mental health conditions. Yet we know that these services are under considerable strain and that, even when sufficient resources are available, families and individual citizens complain that different workers often fail to work collegiately to provide coherent packages of care. If community-based health and social services were better integrated, it would be easier for individual providers of care to deliver appropriate services, as indicated in some of the vanguard sites. This also includes successfully reducing delayed transfers of care.

I have two further suggestions that I would like the Minister to consider. First, there should be a move towards more clinical treatments for people in their own homes, care homes and nursing homes. In Spain, it is not uncommon for a person with pneumonia to be treated with intravenous fluids and antibiotics in a nursing home, and even occasionally in their own home, without the need for hospital admission. Serious consideration of more simple treatments being given outside acute hospitals needs to be undertaken. This would reduce the need for more hospital beds and allow a redistribution of resources towards community-based interventions.

Secondly, all healthcare workers should be expected to be proficient in coronary pulmonary resuscitation and physical first aid. The APPG recently heard, when reviewing progress against the five-year mental health strategy, that there is a real need to increase training in acute in-patient first aid across society. I very much hope that we will do this.

Nursing and Midwifery (Amendment) Order 2018

Baroness Watkins of Tavistock Excerpts

Monday 25th June 2018 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I support the Minister and the Motion to approve the Nursing and Midwifery (Amendment) Order 2018. I acknowledge the challenges that the noble Baroness, Lady Thornton, has raised, in particular those that the Royal College of Nursing is concerned about, but believe that they are capable of resolution. I believe that the registered nurses who stand today will ensure that substitution does not happen for the roles that they really must undertake themselves.

I qualified as a nurse in 1976, when we still had enrolled nurses. For some time, I led a team that included enrolled nurses, but I was very clear, both as a district nursing sister and as a ward sister, that I was accountable for the elements that I delegated. That did not mean that enrolled nurses were not able to undertake routine care by themselves unsupervised, but rather that they were very aware of how to get help when they needed it. I believe that, if we get the nursing associate role right, a similar structure will occur.

I applaud the fact that nursing associates will have a clear ladder—probably through the apprenticeship route, as the noble Lord has just raised—to enable those who want to and who are capable to get university-level associated registration as a nurse. I do, however, regret that we have not called this new role a “healthcare associate”, because I believe that some of the work they will do will be undertaken in social care as well as in routine nursing care. We may need to reflect on that in years to come.

I also want to make it clear that this route should enable people to come relatively young into an adjunct profession that is associated, without them necessarily having A-levels on entry. That is important, because we know that a lot of young people would like to go into nursing or associated healthcare roles but are not able at that point to enter a three-year degree course. This is why I am so supportive of the structure.

The order makes provision for the new role of nursing associate to be subject to professional regulation by the Nursing and Midwifery Council. As has been explained, the first cohort should qualify in January 2019 and it is important for this legislation to be approved in sufficient time for the Nursing and Midwifery Council to open the register and put in place safe and effective standards and requirements for new staff entering the workforce. By regulating the role, the Nursing and Midwifery Council will contribute to the protection of the public by ensuring that nursing associates have high standards of education, will be required to keep their skills and knowledge up to date, and will be held accountable to a code of conduct.

As others have said, this new role has been rapidly developed as the result of successful work between employers and educational providers, with leadership from the CNO for England, Professor Jane Cummings, and the lead nurse at Health Education England, Professor Lisa Bayliss-Pratt, both of whom should be commended for their tenacity and work to achieve this end despite reluctance in some areas of the profession.

To reiterate an issue recently raised by the noble Lord, Lord Willis, many overseas applicants will want their qualifications recognised in relation to the nursing associate qualification, particularly licensed vocational nurses from a variety of Commonwealth countries. I urge the Government to ensure that proper funding is made available to map similar qualifications across the world so that we can make sure that we protect our own public if we allow overseas registrants to apply for this kind of qualification. It may be that they will need some kind of top-up, depending on the final standards that are agreed for nursing associates here.

I am aware that there have been challenges at the NMC recently but I echo the point of the noble Lord, Lord Willis, and acknowledge the commitment of the Chief Executive and Registrar, Jackie Smith, which has ensured that nursing associates will be registered at the NMC in order not only to protect the public but to achieve a proper career route for nursing associates if they wish to proceed to study for registration as a nurse in the future. In the longer term, I hope the nursing associate route may provide a successful apprenticeship approach for some members of the public to become registered nurses, without necessarily having to enter graduate-level study at a time that is not suitable for all.

[Lord Clark of Windermere (Lab)]

My Lords, I too welcome the order; I am struck by the knowledge of the noble Lord, Lord Willis, obviously, and of the noble Baroness, Lady Watkins, from her own practical experience. It is right and proper that we have this debate because a number of questions ought to be raised. To be fair to the Government, they have not been able to answer all the questions beforehand because, as we all know, this order is somewhat rushed. I understand the reason why and I concur with it.

As the Minister mentioned, the order was laid on 17 May; that is absolutely right, but it was first laid on 11 May and had to be withdrawn because it was inaccurate. That is an example of how the legislation has been rushed. It is therefore important that we, as a legislature, challenge the Executive on a number of issues. As has been indicated—the Minister understands this—the Government have consulted widely to try to get the feeling that, if the report by the noble Lord, Lord Willis, was implemented, it would be done in a sensible and correct manner. However, there has been a problem in that a number of the consultees have a vested interest. For example, the local commissioning trusts have an interest about who is going to pay for this. Will the funding come from the centre or from them? I shall come back to that point in a moment. Obviously the providers—the universities—have an interest because they need the income from running these courses. But of course I now see, and this is slightly worrying, that it is not only higher education institutions which are involved—further education institutions are too. The noble Lord, Lord Willis, possibly referred to this point when he said that he was “slightly concerned”—I emphasise the word “slightly”—that there could be some downgrading of the teaching input.

However, one group has not really been represented in these consultations: the nurses themselves. People will refer immediately to the Royal College of Nursing and its equivalent for midwives. But the trouble is that that organisation, in terms of this area, also has a vested interest. It is a registration body for nurses, yet at the same time it is a member organisation and there can be a conflict of views which I have come across quite often. I have no problem with the RCN registering nurses because it is both right and sensible, but we must recognise that there is a potential difficulty. I have talked to a number of nurses who are concerned about nursing associates. However, they can be reassured by this order. As the noble Baroness, Lady Watkins, and the noble Lord, Lord Willis, have both said, nurses are professionals. Indeed, the noble Lord, Lord Willis, made a very wise point. The pivotal role of caring in hospitals ought to rest with registered nurses. That is where we ought to begin because they are professional people.

Even so, nurses are concerned that their views have not always been represented in this consultation. I am therefore pleased to note that paragraph 7.20 of the draft Explanatory Memorandum makes that clear. I shall repeat that because it is important that it is on the record and nurses can see what the position is. The Government say, quite rightly:

“Nursing Associates are identified as a separate profession with different qualifications and education and training to nurses and midwives”.


Nursing associates are not nurses. They are not fully qualified and registered so in that sense they do not represent a challenge to nurses. That point must be rung out aloud because we need to ensure that a profession which is under pressure and suffering from low morale is reassured.

Paragraph 7.9 provides even more reassurance when it makes it clear that nursing associates will not be capable of,

“providing, supplying and administering medicines”.

That too needs to be shouted out. Moreover, I assume—perhaps the Minister can confirm this—that this includes giving injections. I should think it does because it refers to “administering medicines”, but we need clarification. The point is reinforced where the draft memorandum talks about situations of national emergency, when nurses and midwives can be empowered to prescribe. A flu pandemic is cited as an example. That is very sensible because we need the hands and brains of these people to do the job. Nurses help doctors, but it is made quite clear that the education and training of nursing associates is not of the same high standard as that of registered nurses. They will not be allowed to prescribe medicines in a national emergency situation or even a hospital emergency situation. I have spoken at some length, more than I would normally, but this House perhaps needs to help the Government to reassure qualified nurses that their status is not under threat.

I will deal with one or two other points. Paragraphs 7.14 to 7.16 talk about the two-year pilot courses. We understand why they were brought in, and I hope that we have learned a lot from them. Perhaps I might press the Minister on the number of people pursuing nursing associate courses at the moment. The Health Education England plan is for 5,000 nursing associates in training this year. I recollect a debate not long ago in this House in which the number of nurse associates in training was given not as 5,000 but 30—not 30,000 but 30. The Minister said, “I’m pretty sure those figures are wrong—they are too low—but the figure is disappointing”. I wonder whether he has up-to-date figures for the number of students expected to be on NA courses this year, because the projection is important in planning ahead for the workforce.

Long-term Plan for the NHS

Baroness Watkins of Tavistock Excerpts

Tuesday 19th June 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness makes a good point from her experience. There is agreement across the House—and, indeed, across both services—that there needs to be an integrated service. It is clearly not satisfactory to delineate in the way that we have done historically. How we get there will obviously be difficult. We need the NHS and local government to take the lead and to come up with proposals. If we believe that those proposals will deliver what we want without creating upheaval, it is incumbent on us all to get behind them.

[Baroness Watkins of Tavistock (CB)]

I welcome this additional contribution to the health service. However, have there been overoptimistic algorithms on improving productivity? We know that staff are currently stretched, and to expect continued productivity increases before we invest in modern technology will result in more staff leaving, and that would not be rational.

[Lord O'Shaughnessy]

The noble Baroness makes an excellent point. We know that NHS staff do a wonderful job and work incredibly hard. In talking about productivity it is wrong to think of it only in terms of getting more out of the same people. The wage bill, I think, makes up around 40% of the total NHS spend, a great deal of which is on buildings, on items and on technology. We need to use more technology so that we can deliver the productivity gains that we need.