NHS: Winter Funding

Baroness Watkins of Tavistock Excerpts

Thursday 11th January 2018 Lords Chamber

[Lord Clark of Windermere (Lab)]

My Lords—

[Baroness Watkins of Tavistock (CB)]

My Lords—

[The Lord Privy Seal (Baroness Evans of Bowes Park) (Con)]

It is the turn of the Cross Benches.

[Baroness Watkins of Tavistock]

My Lords, will the Minister ask the newly named Department of Health and Social Care to consider funding a pilot of four weeks of social care on discharge for frail elderly people to assess whether this would release patient beds and enable in-depth assessments to be made of future needs? This should be done now rather than wait for a full evaluation to be made.

Mental Health Care: Vulnerable Children

Baroness Watkins of Tavistock Excerpts

Tuesday 28th November 2017 Lords Chamber

[Lord O'Shaughnessy]

I ask the noble Baroness to write to me on that specific case. Of course, health services should never be withheld on such a basis; they should be provided on the basis of need, as we all know. I can confirm that the Green Paper will be published before the end of the year.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister explain why some looked-after children who have been on waiting lists for mental health care and are then transferred out of the area for foster care have to start their wait for access to mental health services again, if we have a National Health Service?

[Lord O'Shaughnessy]

I think this picture of a fragmented service is one that the CQC report highlights. One of the ways in which the Government are trying to address that is through incentive payments in the tariff system to make sure that trusts are incentivised to join up care, particularly when children are moving from place to place.

NHS: Wound Care

Baroness Watkins of Tavistock Excerpts

Wednesday 22nd November 2017 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, in his absence for bringing this important debate to this House, and the noble Baroness, Lady Wheeler, for her excellent introduction to the issue. I draw attention to my registered interests, in particular as a lifelong member of the Royal College of Nursing and the current president of the Florence Nightingale Foundation.

Other noble Lords have addressed the issue of improving the strategy for wound care through the development of generic national specifications classed as clinically acceptably and fit for purpose for at least seven wound care and dressing categories. This is an entirely logical approach which the nursing profession broadly supports and is actively involved in designing. My noble friend Lord Kakkar outlined the macro- economic costs of wound management. It is estimated by Guest et al that 2.2 million wounds were managed in the UK in 2012-13, involving 18.6 million practice nurse visits and 10.9 million community nursing visits. In addition, significant nursing time is spent in hospitals, care homes and nursing homes managing wounds, not only in the NHS but in the independent and social care sectors. Therefore, any strategy for the future needs to consider the total cost of treating wounds, not the unit cost of products. Cost estimates need to focus not only on the price of wound treatments in terms of assessment tools, such as Doppler machines, medicines and dressings but also on the costs of treatment time from a variety of healthcare workers including, for example, medical staff, dieticians and podiatrists, while recognising that wound management, particularly in community settings, is predominantly a nurse-led discipline. The noble Lord, Lord Mackenzie of Culkein, gave an excellent overview of the challenges, the types of wounds and the expertise that clinical nurse specialists in tissue viability use in leading teams.

Innovation is central for the future, but I want to concentrate on four issues—the prevention of wounds, the prevention of infection, treatment expertise and sound models of care—through the lens of patients suffering from leg ulcers. Leg ulcers are painful, debilitating and frequently lead to social isolation. How then can leg ulcers be prevented? Some, of course, cannot, but with education many can be stalled and healed in their very early stages and others can be prevented very effectively by maintaining skin integrity through improved nutrition and exercise in at-risk groups. Keeping even small cuts clean and covered while healing can prevent infection entering a wound. Most patients want to prevent infection and will be happy to concur with a suggested treatment plan.

However, I want to give noble Lords one example from my practice when working as a district nurse more than 20 years ago. I was working with a woman in her mid-70s who was housebound with a severe leg ulcer that was not healing despite what was then regarded as best practice in terms of treatment, which involved a particular form of medically impregnated bandage being put on the affected leg by a relatively skilled nurse, because such bandages must not be put on too tightly. I was not as busy as most district nurses are today, so I returned unexpectedly at about 4 pm to see how she was doing. The answer was that, despite my having asked her not to, she was huddled by a two-bar electric fire, which was in effect setting and hardening the bandage, thus doing far more harm than good. After further assessment, I appreciated that she felt the central heating was too expensive to run and turned it on only when I was due to visit. A referral to a charity resulted in some extra funds towards her heating and over the next two months, with additional ad hoc visits from me, her leg healed. She was able to get out and help her nephew a bit in his shop, while regularly elevating her leg, and I was delighted to be able to discharge her. My point is that we now have just over 4,000 district nurses in England, but when I was working in practice there were in excess of 7,000 and I had the time to take the approach I have described.

Despite the pressure that district nurses are under today, they continue to deliver high-quality care. Investment in continued professional development is vital for healthcare professionals if they are to keep up to date and deliver contemporary evidence-based practice, yet CPD budgets for non-medical staff have been steadily eroded. A fantastic initiative has developed. It originated in Barnstaple in Devon and has already been alluded to by my noble friend Lady Masham. It is the Lindsay Leg Club Foundation. These clubs are usually led by qualified district nurses and have between 50 and 200 active members who have had or have leg ulcers. The clubs are gateways for input from tissue viability specialists, podiatrists and nutritionists. Initial results show quicker healing and improvement of ulcers and reduced prescribing costs through adherence to approved treatments, some of which are expensive but cost-effective. The clubs empower patients as stakeholders to work in partnership with professional staff, volunteers and their peers. Leg clubs are built around the notion of promoting peoples’ independence and well-being. This new social model of care is proving effective not only in the treatment of the physical wound but in promoting people’s independence and mental well-being by reducing loneliness and isolation.

Any wound strategy needs to consider how we prepare health professionals to work with groups, encouraging self-care as far as feasible, and how to integrate evidence-based practice through the dissemination of new evidence. There is little doubt that investment in the nursing workforce, particularly in CPD, is as important as selecting the best treatment product.

An RCT in Queensland, Australia, concluded that nursing time and related costs decreased by 36% using the leg club model, leading to the cost per healed leg ulcer being reduced by 58%. When I was practising, I undertook single home visits. These will always be necessary for some patients, but I delight in acknowledging that today’s leg clinic model is one that I would now wish to adopt. I believe it would have benefited my patients more cost effectively than the intervention I undertook, particularly in terms of productivity in nursing time.

The noble Lord, Lord Carter of Coles, in his report, recommends the adoption of single integrated performance in care pathways centred on customers, workforce and finance. These should apply not only to NHS providers but to independent nursing homes and the wide variety of social care services involved in delivering wound care prevention and treatment.

As the strategy for wound care develops, will due consideration be given to further investment in the workforce, including district nurse training, further development of nursing associates, continuing professional development, and customer education to ensure our workforce—which includes patients—can continue to lead the way in cost-effective care for wound management, based on new research evidence and treatment, thereby reducing individuals’ pain and suffering associated with chronic wounds such as leg ulcers?

NHS: Winter Staffing Levels

Baroness Watkins of Tavistock Excerpts

Thursday 26th October 2017 Lords Chamber

[Lord O’Shaughnessy]

My noble friend talks with great authority on this issue and he is quite right. The NHS is offering all front-line health staff free vaccinations. NHS England has confirmed that it will also be paying for care workers in social care settings to get free jabs. Furthermore, we are now, for the first time, inoculating in school children aged between two and eight, who are sometimes known as “superspreaders”. This is to ensure that, if such an epidemic were to happen, we would be as well prepared as ever.

[Baroness Watkins of Tavistock (CB)]

My Lords, will the Minister join me in acknowledging the stance being taken by the NMC in seriously considering changes to the English language test to make it more relevant to nursing practice, while maintaining patient safety? This has the potential to increase significantly the recruitment of overseas nurses in the UK. I also seek assurance that the Government will not cut investment in district nurse training.

[Lord O’Shaughnessy]

I am grateful to the noble Baroness for raising this. We have discussed a number of times the impact of the test on recruitment from countries other than the UK. It is entirely sensible for the NMC to look at this. On nurse training, I hope she will have been reassured by the announcement from my right honourable friend the Secretary of State for Health at the Conservative Party conference that we will deliver a 25% increase in nurse training places from 2018-19 onwards.

NHS: Working Conditions

Baroness Watkins of Tavistock Excerpts

Wednesday 5th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I completely agree with my noble friend. That is one reason why we are taking steps to deal with health tourism and to ensure that people who not only abuse the system but actually abuse NHS staff, which unfortunately is far too prevalent, are properly prosecuted.

[Baroness Watkins of Tavistock (CB)]

My Lords, will the Minister explain how the STPs will be achieved without further investment in continuing professional development so that people such as paramedics and nurses can work effectively in the community?

[Lord O'Shaughnessy]

I can tell the noble Baroness that investment is going into STPs not just in recurrent spending for the purposes she described but, as was announced in the Budget, in capital spending to achieve the transformations that we all want to see.

Queen’s Speech

Baroness Watkins of Tavistock Excerpts

Thursday 29th June 2017 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, before I commence, I should draw attention to my registered interests and remind the House that I am a mental health nurse and a lifelong member of the Royal College of Nursing.

I have welcomed in this House initiatives to widen participation in healthcare higher education, such as higher apprenticeships, the regulation and standards for nursing associates and accelerated postgraduate programmes targeted at mental health and learning disability nursing. To meet the Government’s commitment to increase healthcare student numbers by 10,000, we must continue to focus on monitoring what is happening in the higher education sector, and government must support sustainability and growth.

Following the changes to the funding of higher education in nursing, midwifery and allied health professions in England, we have experienced an average 23% reduction in student applications, although it is fair to say that in some areas the reduction is much higher. Universities are reporting a diverse picture across England, with some feeling confident that they are receiving better-quality applications from highly motivated and committed student applicants, while in other areas there are concerns about the viability of specific programmes such as learning disability and podiatry. Although the university sector has welcomed the funding reforms, it is clear that three areas that are fundamental to the success of higher education healthcare courses remain to be resolved.

First, universities need urgent clarification on the situation of placements in England. To enable growth and ensure student choice, the best model for this would be for placements to be linked to the student and for universities to be involved in the selection and quality of the placements, rather than serving the areas in the NHS where there might be care needs. But if students are paying for their placements, they will expect the right level of supervision.

Secondly, the success of education depends on the expertise of healthcare academic and practice staff. This is a wider UK issue, although the situation seems to have worsened in England recently. We must resolve the issue, with nearly 50% cuts to continuing professional development funding announced in March 2016 by Health Education England for each of its 13 local education and training boards across the country. As a result, some regions have faced cuts of more than 45% to CPD budgets, with further reductions expected this year. It is crucial that there is continued investment in building the clinical expertise of the nursing workforce to ensure that staff remain up to date with changes in healthcare, including technology. These cuts are an extremely short-sighted move, as it is only by equipping nurses in health and care environments with professional development, training and support that our existing workforce can help drive service transformation, particularly in mental health, including mental health in schools. Both the noble Baroness, Lady Cumberlege, and my noble friend Lady Masham have outlined the need to invest in mental health, especially in women’s intensive care. We know that recently patients from the south-west have had to travel more than 300 miles for in-patient mental health services. Clearly, we need to resolve these problems. Without continuing professional development, it will be particularly difficult.

Thirdly, nursing, midwifery and allied health professions are evidence and research-based professions. Research outcomes contribute to patient safety. With Brexit negotiations starting this month, we need to find a way to ensure that our universities across the UK continue to participate in EU research funding and networks, while we look at measures to increase research capacity in the healthcare disciplines. Researchers in these areas include less than 1% of the workforce—a figure that needs to improve dramatically.

Finally, since 2011 there has been a real-terms drop in earnings of up to 14% for NHS nursing staff. In May this year, RCN members voted overwhelmingly to take action on nursing pay. Over the summer, members will be protesting to scrap the cap. The cap forces good nursing staff out of the profession and leaves those who remain overstretched and undervalued. This has a profound and detrimental effect on the standards of care provided. While I am aware of the vote in the other House yesterday, I urge the Government to consider further over the summer whether removing the cap would be positive in retaining and attracting NHS staff, helping to resolve the workforce shortage so well outlined by others, and ensuring patient care. I also believe that this would reduce the need for nurses to join agencies to increase their salary and therefore increase the cost to the NHS.

It is estimated that there is currently a vacancy factor of about 11.1%—or 40,000 registered nurse vacancies in England. Under these circumstances, it is understandable that many nurses in the EU do not wish to come and work in Britain because of the extreme, increased workloads and the stress and fatigue that ultimately result from working in areas where there are insufficient staff to deliver high-quality care to patients. Without better pay and conditions, we will fail to secure the nursing and other healthcare workforce for the future. I urge the Minister to consider the issues raised, protect nursing education and enhance morale and recruitment. Even if this requires an increase in taxation, I believe that the majority of our citizens would support this idea.

Brexit: Nursing Staff

Baroness Watkins of Tavistock Excerpts

Tuesday 27th June 2017 Lords Chamber

[Lord O’Shaughnessy]

I thank the noble Baroness for giving us the opportunity to talk about the fact that we have increased the number of nurses and health visitors by nearly 5,000 since 2010. She is quite right to say that we need more of them; we have a growing and ageing population and higher expectations of what the NHS should be delivering. It is for that reason that we have a number of things in action: we have 52,000 nurses in training; we have a return to practice programme, which has already prepared 2,000 nurses to come back into the profession; and we are introducing nursing apprenticeships and nursing associates. We are not complacent about this issue—we know it is important—but there are a number of programmes in train to fill the gap that she has identified.

[Baroness Watkins of Tavistock]

My Lords, perhaps the Minister could consider that one of the reasons that people are not coming from the European Union is that they feel unwelcome; housing is almost impossible to get, particularly in some of the metropolitan areas; the reduction in the value of the pound against European currencies means that salaries have stagnated even more for some of these people; and, actually, morale is so poor in parts of the health service and social services that people would rather remain and work in their own countries.

[Lord O'Shaughnessy]

I reiterate the point that the Prime Minister made yesterday about the welcome, and indeed the offer of settled status, not just to nurses but to any other EU citizens and workers in the country. It is absolutely not the case that they are unwelcome—quite the opposite. They are as valued as much as any other person working in the health service. The noble Baroness mentioned housing, and she is right, of course, that housing is a huge issue for everybody. Indeed, one thing that I want to look at in the next few years is how we can take surplus land that sits within the NHS and make sure that some of it is used to provide the kind of key-worker housing that nurses, doctors and, indeed, other members of the public sector can use, so that they are able to come into the service and support our hospitals.

Education (Student Fees, Awards and Support)(Amendment) Regulations 2017

Baroness Watkins of Tavistock Excerpts

Thursday 27th April 2017 Lords Chamber

I believe that the Government’s approach is a high-risk one; when you have such a large shortage, there must be other ways to deal with it. Why can we not for a number of years lift the cap on universities and say, “Look, train as many as you possibly can.”? If the Government are not prepared to drop the scheme, why do they not say to nursing students who go on to spend a number of years working in the NHS, low paid as it is, that they will write off their tuition fees? That would be one way around it; it is belt and braces, I accept, but I do not believe we can risk what the Government are proposing. It is high-risk indeed, and that is why it should be debated, as it is now. It is interesting and important that we have a full debate on this issue.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interests as outlined in the register and I believe that this afternoon I am the only registered nurse in the House. Nursing is the largest profession in the UK, with some 500,000 people on the professional register. It is vital that the international shortage of nurses and allied health professionals is recognised and that more investment is given to meet the demands for healthcare in the future. I agree with the noble Lord, Lord Clark of Windermere, about the need to spend more on health and social care—but not necessarily with his solutions.

There is a need for at least three pathways to becoming a registered nurse. As a profession, we have supported the introduction of an associate nurse route, which should enable people to be paid while learning and working and to proceed ultimately, if they wish, to train for the register through a sophisticated apprenticeship-style route. We have the pilots in progress at the moment. The second important development in the NHS’s recent five-year plan is support in principle for a graduate entry route similar to Teach First, to be known as Nurse First. This is likely to be piloted in mental health and learning disability branches this autumn and would provide an alternative route into nursing.

The third route, which the majority of students follow, is a three-year university programme with clinical placements within both the NHS and other health care providers. The emphasis on hospital placements is not nearly as important at the moment as the need to ensure that students have experience in community settings and care homes—many of which are in the independent sector—because that is where a lot of people are cared for now, as well as at home. I therefore do not believe that we should reinstate the bursary, as we know that a lot of people applied to go to university because the bursary was there and we had a very high drop-out rate in year 1—I was a dean when that was happening, so I speak from experience. There were also some who completed the course but never had any intention of going into clinical nursing. They wanted to go into HR or to become an air stewardess—neither of which I think is a bad thing—but used the bursary structure to get their degree as an entry into those programmes rather than with the intention to spend a lifetime caring.

It would be preferable to invest in the three methods of education leading to registration and to seriously consider giving a bursary for the third year of training when—I agree with the noble Lord, Lord Clark—most students give a huge amount to the NHS and are often pretty indistinguishable in their final six months from a registered nurse. I also fully support consideration of the concept of forgivable student loans following a period of employment in the NHS on qualifying, rather like those granted to some nurses and medics sponsored by the forces during their education provision.

The other thing I want to draw the House’s attention to is that there are 500,000 nurses in the four countries that make up the United Kingdom and that we have invested very little in return-to-nursing programmes and in encouraging them back to work. That action might be the fastest route to getting more registered nurses back into practice.

Finally, I support the concept that the noble Lord has just addressed. Public sector salaries have been significantly tightened in the last few years and there is a definite case that initial starting salaries in the NHS for nurses and allied health professionals should be increased to recognise that they will be expected to repay their student loans from 2020. As a woman, I get very fed up with hearing both in this House and the other House that very few nurses will have to pay back much of their loan because they do not earn very much. That is not the right approach.

I urge any future Government to invest further in health and social care in order to recruit and retain healthcare professionals. Currently, the ratio of women to men in nursing is nine to one and has remained unchanged for many years. We spend significant time and money on recruiting female engineers; perhaps we should do similarly to encourage more men into nursing and the allied health professions—but I accept that this will be possible only if there is fair remuneration for nurses’ work and funding for continued professional development, as currently happens in medicine. I believe that what I have outlined would be a more strategic approach to the challenges that we face than the straightforward reintroduction of bursaries in the first two years of university programmes leading to registration.

Social Care in England: Older People

Baroness Watkins of Tavistock Excerpts

Monday 20th March 2017 Lords Chamber

[Lord O'Shaughnessy]

On care homes, it is true that some care providers are exiting the system. However, there is the same number of beds and, indeed, there are more nursing homes. So there is churn in the system and there are more home care agencies than there were in 2010. I say that only to point out that it is a changing picture. On carers, she is quite right: this is a long overdue strategy and it will be published shortly.

[Baroness Watkins of Tavistock (CB)]

My Lords, will the Minister explain why the number of mental health and community nurses in England fell between 2010-11 and 2015-16 by 13% to 33,000, as is clearly outlined in the Age UK report? Further, could he explain the recent significant cut in funding at HEE for post-qualifying nurse education, which includes the preparation of district nurses and advanced mental health nurse practitioners? If more people are to be cared for at home, the false separation between social and health care must be acknowledged, particularly if you want to achieve some of what is outlined in the STPs, which we are going to talk about later.

[Lord O'Shaughnessy]

Changes are going on in the nursing workforce and the noble Baroness is right about the cases she points out. It is also worth pointing out that there has been an increase in the number of nurses with general qualifications who are able to work across both health and care, which is important for integration. She will know that there have been changes in the way nursing training has been funded, both in the way she said and in bursaries. However, we are committed to increasing the number of training places available for nurses.

Health and Social Care

Baroness Watkins of Tavistock Excerpts

Thursday 24th November 2016 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I thank my noble friend Lady Finlay of Llandaff for securing this debate, which follows a similar one in my name held in July, referred to by the noble Lord, Lord Colwyn. I will not repeat a lot of what I said in July; instead, I shall focus on the challenges that have begun to emerge over the last three months in relation to nursing and the allied health professionals workforce.

Others have already said that it is vital that we continue to value our EU colleagues who work in the health and social care sectors. The Chief Nursing Officer, Jane Cummings, has joined others in stating the value that we place on these workers. At the moment, we can to some extent continue to recruit from the EU. However, as an example, on a recent visit to Spain it was made very clear to me by some nurses that they no longer seek an opportunity to come and work in the UK because they fear that the very high number of Spanish nurses who are here now will seek to return, and they may then not have jobs if they, in turn, go back to Spain after a short period here. So, as well as what we know from meta-analysis, we are, anecdotally, very clear that things are changing.

Another important point is that we must not over-recruit from countries where there is already a significant shortage of healthcare workers. The report of the noble Lord, Lord Crisp, which looks particularly at the triple impact of nursing internationally, argues that we must be very careful not to do that.

Amid the concerns and possible doom and gloom, this week the Royal College of Nursing celebrated its centenary and I attended part of its conference. A really positive note was the developments in nursing across the four countries of the UK and the absolute commitment to continuing to improve care and support for our communities, working with healthcare staff from a range of backgrounds and countries in the EU.

The UK Government have told us that they want to ensure that the health and social care needs of our population are not negatively impacted by the UK’s exit from the EU. A sound supply of staff is essential, not only for the NHS but for the voluntary and independent sectors. It is estimated, for example, that the independent health sector generates in excess of £2 billion a year for the London economy, with associated tax revenues for the Treasury. As indicated yesterday in the Autumn Statement, we need to keep this kind of business in the UK, and, to get those benefits, we need to provide the staff to deliver them.

Our relationship with the EU has had a substantial direct and indirect impact on the delivery of health and social care in the UK. It has developed really good patient safety standards and improved the quality of care. The staff we have now are central to the successful delivery of care in the future. Because so many others have talked about this today, I do not intend to dwell for long on the incredible support for older people that is provided by staff from the EU, However, it is essential that we develop more home-grown staff.

We need to develop a long-term, coherent workforce strategy and implement plans that maintain and grow the domestic health and social care workforce. The noble Lord, Lord Warner, talked very clearly about the fact that we have failed to do that in the past. There is a terrible fear of over-recruitment. Certainly we need a whole new set of doctors and nurses, but we also need nursing and medical academics to support the rapid increase in such programmes, so it is not quite as simple as it seems. We must ensure appropriate educational and professional regulatory frameworks, including for nurses, nurse associates and social workers trained in the UK, to create a proper professional pathway for young people.

Others have referred to the fact that a lot of the law from Europe has resulted in safeguarding decent working conditions for staff. It is imperative that as we go through the great repeal Bill, we do not undermine some of those advances, such as TUPE and other good standards for those employed.

I turn to the relatively severe concern of funding for the ongoing training of nurses, midwives and allied health professionals, which has been stripped out again this year. Therefore, we have people qualifying who would like to develop their career, but who cannot afford to because of the post-qualifying costs of further and higher education.

We have not seen any campaigns to successfully promote nursing as a career such as those we have recently seen for teaching. Of course, I finished writing my speech last night and then read the Metro on the way in this morning, in which there is a fantastic advert for nurses to return to practice in London—there are always exceptions to the rule. However, we need to fundamentally encourage people to come into nursing and the allied health professions, particularly as they will be starting to pay their own fees. We cannot do this too soon.

There are steps we can take that will protect against nurse shortages. Noble Lords will know that I have consistently argued that postgraduate pre-registration courses that supply nurses for the NHS need protection. I am delighted that the Government have committed to continue funding these in 2017-18, but that needs to continue until at least 2020.

My noble friend Lady Finlay described the numbers and challenges we will face if our EU friends decide to move. However, all the figures on NHS-funded nurses fail to take into account the shortage in specialties in mental health, largely because most of the child and adolescent mental health services are provided by private companies contracted by the NHS. There is already concern that recruiting to mental health and learning disability nursing programmes next year may prove difficult. We need to keep a watchful eye on this and ensure that we can retain and recruit in those areas.

Common EU standards for training and recognition of qualifications have enabled mobility, raised educational standards and improved health. Other activity, including research collaboration, has developed nursing practice. I trust that the Minister will give careful consideration to some of the challenges we have raised, particularly how we will staff mental health and learning disability services in the future.