Nursing

Lord Hunt of Kings Heath Excerpts

Thursday 1st December 2011 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, in thanking the noble Baroness, Lady Emerton, for her splendid opening to our debate, I declare an interest as chair of the Heart of England NHS Trust and as a consultant and trainer for Cumberlege Connections. I also acknowledge my noble friend Lord MacKenzie on the Front Bench. I suspect that what he does not know about nursing is not worth knowing; it is very good to see him there.

This is a very timely debate. We all agree that the quality of nursing care is fundamental to the quality of the patient experience. However, we are presented with a paradox. On the one hand there have been huge advances in the nursing profession over the past 20 years. There has been the move to it being a graduate profession. Nurses have taken on much greater responsibility. There is complex care and specialist nurses, in both hospital and the community, as the noble Baroness, Lady Jolly, so vividly informed us. I think also of midwifery. If the noble Baroness, Lady Cumberlege, were here, she would be able to talk about changing childbirth and how the profession was encouraged to take on a huge leadership role. The public have welcomed the increased responsibility that nurses have taken on.

At the same time there has been a mounting concern about basic standards of care and issues to do with hygiene, the feeding of patients, nutrition, dignity and even face-to face contact. This has been reinforced by several reports from unannounced visits and the CQC over the past few years. There have been any number of investigations of concerns about what seems to be a falling off in basic values of care. What is the reason for that? My noble friend Lady Warwick convincingly demonstrated that the old canard about modern nurses being “too posh to wash” just does not stack up. However, there are a number of questions that one might ask. There is a real question about whether nurse training is too focused on academic performance rather than on practical nurse training.

I also wonder whether the drive for specialist nurses and modern matrons has removed too many experienced nurses from the ward or the equivalent within the community. Has the lack of regulation for healthcare assistants led to patchy and inadequate care in some places, despite the undoubted dedication of many of them? We need some serious thinking about how to enhance quality overall and the standards of basic care that nurses give. Certainly, in my own trust a lot of thinking has gone into the quality of nurses. I claim no credit for it. While we do not have matrons in starched caps, we certainly have visible chief nurses in purple uniforms walking the wards as a visible demonstration of nurse leadership, which has been warmly welcomed. Anyone who wants to see nurses really dressed up should go to the Florence Nightingale service in Westminster Abbey once a year. I always hope that the chief nursing officer will come in uniform—alas not. To see the chief nurses of the Army, Navy and Air Force marching up the aisle is a wonder to behold. The reason why the public like to see it is that they want to see nurses in authority. They want them to have the confidence to be leaders in the ward, in the community and in the health service as a whole.

Another thing that we have done is to develop a robust measurement of nurse standards by polling 400 patients a month, looking at the results, reporting to the board and trying to identify any problems with nursing care. The third thing that we have done is to develop VITAL—virtual interactive teaching and learning. Essentially, it assesses all nurses online for their knowledge of best practice in fundamental care. This covers, for example, nutrition, falls, privacy and dignity and pain management. Since the summer, 60 per cent of our trust’s workforce have achieved 100 per cent in that online examination. Our intention is that from next year all newly qualified nurses and midwives will have to achieve 100 per cent within six months or they will not get the substantive contract. We also expect our nurses and midwives to sign up to a code of values and behaviour. We are introducing a badge for our nurses which will be achieved only if they get 100 per cent in the online test, sign up to our values and have evidence that they are putting those values into action. The noble Baroness, Lady Emerton, will certainly remember the badge, which nurses wore with pride. It showed where they came from and who they were; for example, the Tommy’s nurses. We need to get some of that ethos back into the health service.

We have done a lot but there are a lot of issues around the training and education of nurses. I do not disagree with the requirement for nurses to have a degree. I do not think there is any argument about that. However, we have thought about how a foundation trust could be much more involved in nurse education and in supporting students in practical nurse training. We wanted to facilitate a practice-based model built around the trust which promoted our core values but adhered to national standards and the curriculum as laid down by the Nursing and Midwifery Council and with appropriate academic accreditation. It is fair to say that our proposal has not met with universal acclaim. Indeed, I feel that all the establishment bodies concerned with nurse training and education have put a real dampener on this. We have been accused of turning the clock back to the old schools of nursing. That is a bit unfair to some of the old schools of nursing because they were pretty good. However, we are not trying to do that. We seek to facilitate a more practical-based nurse education degree, which would have degree status but would be built much more around the hospital and its values. I do not think that this discussion is at an end. I believe that we will soon have a new chief nursing officer to follow on the excellent current CNO Christine Beasley, if one has not yet been appointed. This must be one of the main focuses of the new chief nursing officer. What could be more important than sorting out the education and training of nurses?

The noble Viscount, Lord Bridgeman, and the noble Baronesses, Lady Jolly and Lady Masham, were right about the role of senior sisters, or their equivalent, in the community. We need to empower them to lead. That means they have to have control of the budget so that whoever is providing the cleaning or the food, whether it is directly employed people or contract cleaners, none the less when the senior sister wants something to happen there is no question but that it happens. We need to give our senior sisters much more confidence and support to take on a leadership role. We need to go back to the days when doctors were a bit scared of the senior sister because she is in charge and she is the person on whom the patients depend for the overall quality of care. Making our senior sisters supernumerary so that they can focus entirely on leadership and management will cost us £1.6 million. It is a challenge to find the resource to allow them to focus much more on leadership. The problem with being drawn back into being counted as one of the qualified nurses on wards is that they then get so focused on caring for patients that they just do not have the time to carry out the leadership role that is required.

I urge the noble Earl to take account of two further points. My noble friend Lady Warwick talked about the lack of UK research in relation to basic nursing standards. The noble Earl will not be surprised to hear that there is an issue with regard to the amount of money spent on research into nursing. I know of the efforts made by the department over the years to give a boost to the amount of money spent on research in relation to nursing but clearly we need to go somewhat further in that regard. We probably need to have more academics who can focus on research.

With regard to healthcare assistant regulation, the Government’s response is to have a voluntary register. I suspect that there will be a halfway house and that it will not be long before some NHS organisations will say, “You can’t be a healthcare assistant with us unless you register voluntarily”. I hope that training programmes will be set up but, for the reasons that the noble Baroness, Lady Masham, has given in terms of safeguarding the public, the argument for regulation is becoming ever more persuasive.

I hope the noble Earl recognises that the number of nurse training places should be determined by Ministers. If he devolves that issue, he will find that in times of financial difficulty the number of training places will be cut. I would give much more discretion to the NHS locally to determine arrangements with universities regarding the provision of graduate education for nurses. However, history tells us that the moment the department relinquishes control of the number of training places, the health service does the wrong thing. I know that we are debating the tension between national leadership and local discretion, but national leadership is required in some areas, and this is one of them.