Care Quality Commission: Morecambe Bay Hospitals
Lord Hunt of Kings Heath Excerpts(12 years, 6 months ago)
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Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl for repeating the Statement, and I declare my interest as a consultant trainer with Cumberlege Connections and as chair of the Heart of England NHS Foundation Trust. Yesterday’s report will have left your Lordships shocked. The noble Earl began with an apology and we on this side of the House echo that apology. Of course, it is a sad fact of life that mistakes will be made. What is never acceptable is when people or organisations try to hide those mistakes. Sadly, this is what appears to have happened in this case.
The report covers a four-year period up until autumn 2012 and deals with failures in regulation, but also with subsequent attempts at a cover-up. It was only published thanks to the efforts of James Titcombe and his family, and I echo the tributes that the noble Earl has paid to him. It is essential that he and all the other families affected in Lancashire and Cumbria get the answers they are looking for. We on this side of the House are fully committed to making sure that this happens.
The most shocking revelation in this report is that in March 2012 an instruction was given by a member of senior management at the CQC to delete the findings of an internal review. Today’s report says:
“we did find evidence of the apparently deliberate suppression of an internal CQC report … and the alleged decision to suppress it … may constitute a broader and on-going cover-up”.
When one considers the context in which this takes place, it is truly shocking. At that time, we were almost two years into a public inquiry into the failings at Mid Staffordshire. That followed an earlier independent inquiry, also led by Robert Francis, following which all parts of the NHS had committed to full openness and transparency. It came after failings at other trusts, most notably Basildon and Thurrock, had been made available, which led to the Opposition calling for an in-depth look at hospitals and a new assurance that they were safe. That is why yesterday’s report is so hard to comprehend. It raises serious questions for the CQC and the Government, which I will take in turn.
On the question of the CQC, I agree with the noble Earl’s assessment of the quality of the new leadership team at the CQC. I commend the new chief executive, David Behan, for commissioning this report. However, yesterday the chair, Mr David Prior, said that he wants to draw a line under the issue. Does the noble Earl agree with me that that line can be drawn only when further questions about the report are answered?
On the cover-up, paragraph 1.17 of the summary of the report says, as I said earlier, that the order to delete,
“may constitute a broader and on-going cover-up”.
Will the noble Earl address this point directly and tell the House whether he is confident that this cover-up is no longer happening? Is he satisfied that the CQC is taking all appropriate steps, and does he have full confidence going forward, or does he believe that a further process of investigation is necessary?
More specifically, is anybody who is involved in the decision to delete that report still working at the CQC or elsewhere in the National Health Service? If they are, I think the public will find that very hard to accept. Given that accountability is essential, does he agree that the public would find it very hard indeed to accept data protection laws standing in the way of this? Will he therefore review the decision to shield the identities of those involved?
The noble Earl will probably have heard the Information Commissioner, speaking today about the use of the Data Protection Act, saying, as I understand it, that there is no blanket ban under the Data Protection Act that would deal with a situation like that, and that if there is an overriding public interest in the names being in the public domain, the Data Protection Act should not be prayed in aid.
I know that the CQC is now seeking further legal advice, and that is welcome. In the end, does the noble Earl agree that sometimes organisations have to override legal advice and do the right thing? I hope the CQC will do that and do it quickly.
Turning to the noble Earl’s department, can I just have it confirmed that the decision to delete the report was taken solely by senior management at the CQC? Can he confirm that officials in his department were not aware of that deleted internal report and were not involved in any discussions between the CQC and the department about it?
Yesterday, at Prime Minister’s Questions, the Prime Minister said that there should always be support for whistleblowers, and he was right. However, there are serious doubts about whether that happened in this case. Concerns about the CQC were raised by a whistleblower, but I understand that she was then subject to attempts to remove her from the CQC board. The noble Earl will recall that I raised this in the House, and he very kindly took action on the matter. It has been reported that the same whistleblower told the CQC board yesterday that she raised issues internally first and then within the department, including directly with the then Secretary of State, in a meeting. Is the noble Earl prepared to release the minutes of those meetings?
We note the important work of Mr Don Berwick, but should we not be getting on with implementing the recommendations of the Francis report in this regard? The Care Bill, which is now in your Lordships’ House, is an ideal vehicle for implementing Francis but is remarkably light on clauses relating to Robert Francis’s recommendations. His report emphasised the need for openness, transparency and candour. Openness will enable concerns and complaints to be raised freely and without having questions to answer. Transparency will enable the truth about performance and outcomes to be shared with everybody with an interest in it. Candour will ensure that any person harmed by the provision of a healthcare service is informed of that fact and an appropriate remedy offered.
Francis made specific recommendations, including that a statutory obligation should be imposed to observe a duty of candour. He wanted healthcare providers who believe or suspect that the treatment or care provided to a patient has caused death or serious injury to inform that patient, or a duly authorised person, of that fact as soon as practical. He said there should be a statutory duty on all directors of healthcare organisations to be truthful and that it should be made a criminal offence for any registered medical practitioner to knowingly obstruct another in the performance of the statutory duties that he wished to see enacted, to provide information to a patient or nearest relative intending to mislead, or to dishonestly make an untruthful statement. However, the only offence in the Bill is a corporate one of providing “false or misleading information”. That is not a duty of candour, so I was very surprised to see the Secretary of State say yesterday in the other place that there would be a duty of candour in the Care Bill. It is not in the Care Bill and I do not think that secondary legislation is sufficient.
Does the noble Earl also not agree, in the light of what happened at the CQC, that it is perverse that the duty not to provide false or misleading information applies only to providers? It does not apply to the CQC; to the other regulator, Monitor; to NHS England; or to his own department. Is he prepared to agree to amendments to the Care Bill on Report to extend this duty to the organisation that has been found so grievously to suppress information that it found itself uncomfortable with?
There is clearly a real problem about the approach that the CQC has taken to hospital regulation. Is the noble Earl willing to have a lengthier debate about regulation? I wonder whether we are just putting too much responsibility on regulators and not enough on the people who actually provide those services. I particularly worry about what he says about the introduction of Ofsted-style ratings into the health service. He will have seen evidence from a number of medical bodies, which are concerned that this is going to be too simple a process when judging something as complex as a hospital.
A hospital may be given a 1 rating—an outstanding rating Ofsted-style—but inevitably within a large hospital, although overall it may be a category 1 there are likely to be services that are not so good. My worry is that a hospital, because it has been given a 1, will not then be reinspected for a number of years, which is the Ofsted style, and its weaknesses will go undetected. When at some point a real problem with patient care comes into the open, it will undermine the whole credibility of the exercise undertaken by the CQC.
We know that the CQC has really been pushed into this by the Government and the Prime Minister. I hope it will be given the flexibility to come up with a more sophisticated approach. We do not want to set the CQC up for failures in the future. I am very fearful that a simple grading of 1 to 4 is almost guaranteed to do that. Overall, I am glad the Government have brought this Statement to Parliament. It is very important indeed that the messages and lessons are learnt. However, we need a much wider debate about the role of regulation in the health service and about whether the practicalities of this can be taken forward effectively by the CQC.
Health: Children's Heart Services
Lord Hunt of Kings Heath Excerpts(12 years, 7 months ago)
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Lord Hunt of Kings Heath
My Lords, I thank the noble Earl for repeating the Statement and for reminding the House of the events which led to the Safe and Sustainable review. Terrible failings in the care of very sick children at the Bristol Royal Infirmary in the 1980s and 1990s led Sir Ian Kennedy to call for expertise to be concentrated on fewer surgical sites, a call supported by more immediate, recent events, including the suspension of children’s heart surgery at the John Radcliffe Hospital in Oxford in 2010. Since Bristol, Sir Ian’s important conclusion has had the support of the health professions and all sides of the House.
As we digest what the noble Earl has said, two considerations must remain foremost in our minds. First, this issue continues to transcend party politics; and secondly, the complexity it presents should not derail us from our determination to deliver the safest possible care for children in the country. That said, changes of this magnitude must be able to command consensus and public confidence and that has not happened since the decision on site selection by the joint committee.
When it was published, while the Opposition supported the reduction in sites, we expressed concerns about the distribution of the seven sites, skewed towards the west of England and leaving a large swathe of eastern England, from Newcastle to London, without a centre. For a family living in Hull or Lincoln, the prospect of leaving home to travel hundreds of miles, with the cost of accommodation and time off work, added to their stress and anxiety. Therefore, it is not surprising that there has been such strength of feeling, particularly across Yorkshire, the Humber and east Midlands. While clinical safety must predominate, does the noble Earl agree that the NHS needs to give further consideration to public access and travel times when reconfiguring services? In this case, as the IRP points out, the joint committee considered access the least important factor. The IRP concluded, surely rightly, that the decision used a flawed and incomplete analysis of accessibility. Going forward, can the noble Earl tell me that his department will ensure that that is corrected and that access will be a significant factor in a future decision?
On the review itself, the noble Earl will know that one main concern has been that mortality data were not given enough weight. While decisions on this cannot be based on death rates alone, we agree with John Deanfield, the director of NICOR, who, in his letter to NHS England in April 2013, said:
“Mortality is only one measure of quality, but currently is the most robust available outcome”.
Will the noble Earl confirm that, in the further process of review announced today, these data will feature more prominently?
The main concern we have with the announcement that the Government have made today is the proposal to link the children’s review with the review of adult heart services and the implications that might have for the timetable. The Statement uses the words “better co-ordination”. I understand that about 30 centres are carrying out adult heart surgery. The seven selected centres for children will not be collocated with adult heart surgery. As the noble Earl knows, there are a number of specialist children’s sites. The link between the children’s sites and the adults’ sites is not at all clear. Is there a danger that, by linking the review with adult heart surgery, the Government risk a loss of focus and, indeed, more delay? By broadening it in this way, is there a danger that we will lose the consensus that has already been gained over the future of children’s heart surgery?
The decision will clearly have implications for the timetable of the children’s review. It is noticeable that the Statement does not really contain a clear timetable. Can the noble Earl set out a more precise timetable for when the actual decision is going to be made?
I wonder whether the noble Earl has seen the response from the Royal College of Surgeons today. It expressed disappointment that the reform plans will be suspended, adding to what it describes as a long and exhaustive process. In its final comment, it urges NHS England to act swiftly and decisively, and says:
“Continued foot dragging will only delay the much needed reform that will ensure children will get the best treatment available”.
Can the noble Earl respond to that? He says that the review will be concluded by the autumn, but the question here is when decisions will be made and, even more importantly, when they will be implemented.
The Statement sets out a major role for NHS England going forward. Can I be assured that, in the process that NHS England takes forward, it will operate independently of interests linked to the selected sites? Does he agree that it is vital that we do not lose confidence in the process and damage confidence in all 10 existing services? I noted what he said in reassuring the House about safety. I welcome that, but is his department taking action to ensure that all existing units will not lose expertise in the intervening period? That will be a source of concern the longer the review takes and the longer the decision takes to make.
It is clearly important that public confidence in the process and the final decision is maintained but, balanced against that, unnecessary delay will not bring the best results for the children who most need our help. In that regard, I should like to ask him about the comments made by Sir David Nicholson, the chief executive of the NHS, at the annual meeting of the NHS Confederation last week. In an interesting speech, he said:
“We cannot let the tyranny of the electoral cycle stop us from making the real and fundamental changes that we need to make to the NHS”.
He went on to say:
“So what happened when we got a new government in is we wasted those two years where you can really make change happen. We spent our time talking about reorganisation and changes and all the rest of it and we didn’t talk about the really important changes that are required for the NHS”.
I am quoting that because the election is less than two years away. Can the noble Earl reassure me that the electoral cycle is not going to get in the way of coming to a sensible and speedy decision?
Care Bill [HL]
Lord Hunt of Kings Heath Excerpts(12 years, 7 months ago)
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“( ) the Medical Royal Colleges;”
Lord Hunt of Kings Heath
My Lords, Clause 98 concerns a duty of co-operation with the Health Research Authority. That is of course absolutely supported. My Amendments 58B and 58C would insert into the list of organisations,
“Medical Royal Colleges … the General Medical Council, the General Dental Council and the Nursing and Midwifery Council”.
I have no doubt that the noble Earl will warn me of the dangers of this, but in a sense his own department has provoked it by putting a list into the Bill. Inevitably, we looked at that and wondered why some organisations were missing. I realise that Clause 98(1)(i) allows flexibility by regulations to add to the list and I am sure that that flexibility is welcome, but we should get this right in the first place. I find it difficult to understand why, for instance, the medical royal colleges are not listed. They have a vital role to play in this area.
Similarly, I support the noble Baroness, Lady Emerton, in her Amendment 59. I am sure she will speak to that in a moment. If the Chief Medical Officer is named, why is the Chief Nursing Officer not? I know there has been concern over the years about the position of the Chief Nursing Officer. The last Government as well as this one have debated this issue. Given that we wish to see an extension of research into nursing and clinical areas because of the absolute importance of enhancing the quality of nursing, it is disappointing that the Chief Nursing Officer is not listed.
I also support Amendment 61 from the noble Lord, Lord Willis, which takes the responsibility in Clause 98(7) of local authorities and NHS trusts to have regard to guidance from the HRA on good practice in research and extends it to other providers, including the private sector. These are important amendments as a whole. It is important that the Bill is informed and improved.
On my Amendment 61A, I am puzzled that in Clause 98(7) the requirement is only to have regard to HRA guidance. Surely that should be strengthened, as in my amendment, which says that guidance “must” be followed,
“unless there is good reason not to do so”.
I have taken advice on this matter. The noble Earl will know that there has been a problem over the years in getting approval for multicentre trial research. I understand that the research ethics committees have improved their performance in recent years, and that is to be welcomed, but we now apparently have the problem with some NHS trusts and foundation trusts. Of course, as this is the start of another Committee day, I ought to declare my interests as the chair of a foundation trust and as a consultant and trainer with Cumberlege Connections. It is disappointing if individual NHS organisations are holding up multicentre research, for all the reasons that we know about: UK plc and the need for us to ensure that there is greater investment in research in the UK. I want some assurance that if there is undue delay, the HRA will be able to intervene and ensure that NHS organisations get on with giving the necessary approval.
On Amendment 60A, health research capacity in the UK is of course one of our strongest assets. It includes pharmaceuticals and medical devices, and takes place in our medical schools and hospitals. World-class research is undertaken here, frequently with outstanding results, yet we consistently fail to exploit that research when it comes to its translation into practice. How many other countries have exploited research undertaken in this country? I very much welcome the establishment of academic health science networks, which are responsible for encouraging much closer links between research and health service practice.
However, there is much more to be done. I would like the HRA’s objectives to include encouraging innovation and practice. It is important that the HRA is in a position to advise the department on potential policies that might have an impact on the scale of research and development in the UK. One such example is the present intention to move away from the current pharmaceutical price regulation scheme method of reimbursing pharmaceuticals. I know that the Government are committed to the introduction of value-based pricing. I always try to tempt the noble Earl to debate in your Lordships’ House the introduction of value-based pricing, principally because very few people understand what it involves. Even having been the Minister who received the original report on it, I must say that I am still in the dark as to exactly how it will unfold.
My key question is this. I know that the PPRS approach is not perfect and that at regular intervals Governments negotiate it downwards, but it has always given flexibility to the industry to price new-licence medicines as it wishes within a profit cap. The advantage of that flexibility is that many new drugs are launched in the UK rather than in other countries. I would like to hear from the noble Earl that the introduction of value-based pricing will not have an impact on the willingness and ability of pharmaceutical companies to continue launching products in the UK. I believe there is a link between the launch of products and investment in R&D in this country.
I may strain the patience of the House, but while I am talking about pharmaceuticals it is tempting to ask the noble Earl about the implications for the cancer drug fund. He knows that the intention was for that fund to become obsolete with the introduction of value-based pricing. However, cancer charities that I have met believe that value-based pricing will apply primarily to new active substance licences from 2014, and will therefore have limited impact on treatments made available through the fund. Will the noble Earl comment, or perhaps write to me, with an assurance that, before firm proposals are made on this issue, full consideration will be given to the impact of value-based pricing on the cancer drug fund, its continuation or potential substitution? I beg to move.
Earl Howe
I understand the issue that the noble Lord has raised. There are a number of ways of exercising leverage on foundation trusts, if I can put it in that rather impolite way. One of them relates to the funding from the National Institute for Health Research. The noble Lord may well be aware that as from 1 April that funding is conditional on the 70-day timeline for the recruitment of the first patient into a trial. If that timeline is not met, the funding does not follow. I can tell the noble Lord that that has concentrated minds rather effectively across the health service, including in foundation trusts, towards achieving a much more efficient and effective decision-making process.
I am aware that I did not answer a question from the noble Lord, Lord Patel, about rationalising the number of research ethics committees, which may well bear upon this issue in another sense. The HRA and its predecessor have made good progress in reducing the timelines for ethical approval, something that stakeholders have recognised. The current special health authority feasibility study is looking at how to address other delays whereby trust decisions can be made based on their capacity and capability to take part in research. This is ongoing work. I come back to my point about the core function of the HRA, which is, above anything else, to protect the interests of patients and the public. It might not be advisable to load on to it too many other roles that could detract from that core function.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl for that comprehensive response. I cannot help thinking that in order to protect the patient and the public there must be recognition that high-quality research is one of the best ways to enhance the quality of patient care. I remain concerned that bodies in the NHS still do not understand the importance of getting their act together in research approval. That does not mean that they do not have to go through a thorough process, because there clearly has to be a rigorous process to protect the public. I would like to see stronger language in the Bill that essentially allows the HRA to intervene if undue delays take place. I hope that we can return to that on Report.
I am grateful for the noble Earl’s comments on value-based pricing. All I would say to him is that I have been disappointed that there has been a great lack of public debate on this matter. I know that the department is shortly to publish further work. It is essential that these ideas are tested, and I am concerned that this is going to be simply a matter of negotiation between his department and the industry without there being a wider discussion of the implications. I appeal to the noble Earl for some opportunity on that.
Finally, the Minister has made it clear that the list in the clause represents bodies concerned with regulation, and that is now well understood. I come back to the question raised by the noble Baroness, Lady Emerton: is there not a case for another clause stating that there is a general duty of co-operation? There is an argument that while, of course, you have your statutory regulators which need to co-ordinate their efforts, you also want a lot of organisations and people to be involved, including the Chief Nursing Officer and the Director of Nursing at the department. I put that forward as a suggestion and beg leave to withdraw the amendment.
“( ) “Significant improvement” is to be defined in regulations.”
Lord Hunt of Kings Heath
My Lords, we now come to Part 2 of the Bill and particularly to Clauses 74 to 77, which may be described as a failure regime for NHS trusts and NHS foundation trusts. Clause 74 makes amendments to the powers of CQC to issue warning notices to those bodies. Where it appears to CQC that the quality of healthcare services provided by a trust requires significant improvement, CQC will be able to highlight those areas in a new form of warning notice. This will state the reasons for CQC’s view, and it will require improvements in the quality of services to be delivered within a specified time. At the end of that period, CQC must review whether the requirements specified in the notice have been met.
Where CQC is not satisfied, it must decide what further action needs to be taken. In the case of a foundation trust, CQC’s review must include use of its power to require Monitor to put the trust into special administration. Clause 75 extends Monitor’s powers to be able to issue additional licence conditions on foundation trusts when CQC has issued a warning notice. At present, Monitor can make use of these powers only if there is a failure in the governance of a foundation trust.
In the event of healthcare services provided by the trust requiring significant improvement, Monitor will as a result be able to take timely action to make changes to leadership or governance with the intention of securing improvements to those services. Clause 76 will enable Monitor to make an audit to authorise the appointment of a trust special administrator in cases where it or CQC is satisfied that there is a serious failure by an NHS foundation trust to provide healthcare services of sufficient quality and that it is appropriate to make the order. At present, Monitor is able to authorise the appointment of a trust special administrator only in cases of insolvency. Monitor may make an order when it is so satisfied, but must make the order when required to do so by CQC.
Let me say at once that the Opposition support the intention of giving greater emphasis to safety and quality and enhancing CQC’s powers in this area. Of course, we are very much influenced by the report of Robert Francis on Mid Staffordshire. We also welcome the introduction of a single failure regime, focused on quality as well as financial failure. However, I suspect that I am not the only noble Lord to have been confused by the respective roles of CQC and Monitor when reading this Bill. Indeed, I was surprised that the Department of Health boldly claimed in its factsheet that the new failure regime will give regulators clear roles in tackling failure. I must say that I found it anything but clear. The factsheet says:
“The Care Quality Commission … will focus on exposing problems and requiring action while Monitor and the NHS Trust Development Authority … will focus on intervening if a poor-performing provider is unable to resolve the situation working with commissioners”.
To confuse matters further, CQC retains enforcement powers for social care, general practice and independent sector providers. That is going to be very confusing. I also pose the question as to whether there are not going to be significant risks associated with these changes. As Robert Francis made clear, regulatory complexity can contribute to system failings. It is important that we get this right, so there are a number of matters which I would like to put to the noble Earl, Lord Howe.
Does the Minister consider that with this level of complexity, there is a risk of slowdown in the action required to address failures? How will Monitor, CQC and the NHS Trust Development Authority work together to ensure that problems are acted upon? Will Monitor and the NHS Trust Development Authority be able to question CQC’s findings and recommendations? What happens if those three august bodies disagree about whether action is needed? Will Monitor and the NHSTDA be equipped to come to their own views on quality, or do they have to take the view of CQC on trust?
The noble Earl will know that the potential confusion has been examined recently by the Health Select Committee. Indeed, the Secretary of State explained to the Commons Health Committee that the change in the arrangements so that CQC in essence has to refer concerns to Monitor, which then takes enforcement action, is devoid, as he put it, of conflict of interest when an inspector identifies a fault then later feels obliged to say that there is no longer a fault, simply to avoid the enforcement action appearing ineffective. However, that does not apply to the other sectors. It does not apply to social care provision, general practice or the independent sector. I do not understand why there is deemed to be a conflict of interest in relation to NHS foundation trusts and NHS trusts but not the other bodies. Nor does it apply to other sector regulators, such as the Health and Safety Executive or the Civil Aviation Authority. There are plenty of examples of regulators that monitor and also take the enforcement action.
I also do not understand why, when it comes to healthcare, the NHS has a different regulatory regime from that of the private sector. Surely, there ought to be consistency in approach. The noble Earl will know that we have had the fair playing field work undertaken by Monitor, as a result of discussions on the previous Bill. It does not seem that there is a fair playing field when it comes to regulatory machinery in relation to, say, the independent sector and to the NHS, even though they are both providing services under NHS contracts. I very much welcome Amendments 65, 66 and 67, tabled by my noble friend Lord Warner, and I would add to them my Amendment 66ZA, which would ensure that the NHS is dealt with equivalently.
On the NHSTDA and the NHS trusts, there is a puzzle regarding what appears from the architecture. I think it is generally accepted that those trusts which have not yet reached foundation trust status are generally considered to be the weaker organisations, given that NHS foundation trusts were introduced quite a number of years ago now. What is puzzling is that the weaker organisations seem to come under a weaker regulatory system. I will be interested to hear my noble friend Lord Warner’s remarks concerning his amendments, but it appears to be a puzzle and an inconsistent approach.
This also takes us back to the recommendations of Robert Francis concerning the merger of regulatory functions, which he suggested in his report that the Government should consider. On the fact that the Government have got themselves into such a tangle on the respective roles of CQC and Monitor, while I can well understand nervousness about having yet another restructuring in relation, for instance, to CQC—given the number of changes that have occurred to the care regulator over the years—I worry that they have come up with such a complex solution that I wonder whether merger might not come to be seen as the easier option.
I would also like to raise some issues about the process under which the failure regime takes place. I start with my Amendment 64A, in relation to the Section 29A warning notice under Clause 74(3). Can the noble Earl give some indication of how the significant improvement required is to be defined and assessed? Can he also say how proportionate CQC will be? Under proposed new Section 29A(2)(a) of the Health and Social Care Act 2008, which is introduced in Clause 74(3), a warning notice will state,
“that the Commission has formed the view that the quality of health care provided by the trust requires significant improvement”.
Is there not a need to clarify either in the Bill or in secondary legislation how “significant improvement” is to be defined and assessed and, specifically, how and where the warning notice applies given the number of multisite trusts offering a wide range of services?
In Clause 75, reference is made to Monitor’s imposition of licence conditions. What criteria will impact on Monitor’s decision to impose those licence conditions? Should they not be subject to statutory guidance, given the serious impact of their imposition? In view of the service implications for NHS trusts and NHS foundation trusts of CQC and Monitor interventions, ought there not to be a clear appeals process for providers, given the potential serious consequences for an individual trust or a local health economy of a warning notice or a “failure to comply” administration, both for the provider concerned and the other providers that may be affected by that decision?
My Amendment 66ZB deals with the multisite issue by requiring CQC to define how this is to be assessed. My Amendments 66ZD and 66ZE seek to have published the Monitor criteria under which a licence condition is issued following a warning notice. When such a warning notice is issued, a foundation trust should have the right to appeal under my Amendment 66ZC, which is consequential on Amendment 66ZE. The same principles apply to Clause 76 in relation to the regulator. CQC must surely publish criteria on following a transparent process in making judgments on trust special administration, where there also ought to be an appeals procedure.
It seems that there is a lot of work to be done to make sure that the health service and other providers fully understand the new regulatory apparatus that is to be brought into being. I remain concerned that there could be confusion between the two roles of Monitor and CQC and that the NHS Trust Development Authority’s role is rather mysterious. It is hard to understand why NHS trusts are not in fact subject to a much more robust process than other providers because, as far as I can see, apart from a number of community trusts which are likely to get foundation trust status, the intention is that we simply roll on for years to come with these unviable organisations. Money is clearly top-sliced in order to keep them going, and we know that the real issue is, in many cases, a failure to tackle reconfiguration. It is a worry that almost a limbo situation is being created in which no progress at all is going to be made. There is also a very clear need for due process as to how these licensing provisions are to operate and an appeal process for any organisation that is affected by them.
If the noble Earl, Lord Howe, would agree to the principle of that, I think he could look forward to general support within the health service and outside and, of course, public confidence. The overriding principle of making sure that quality and safety are considered at the same level, or even a higher level, than that of financial viability is one that we certainly support from these Benches. I beg to move.
Lord Hunt of Kings Heath
My Lords, I will not detain the Committee other than to say that the noble Earl’s response bears careful reading. I am still confused about the role of the CQC. If it is able to enforce action against non-NHS social care providers, I do not understand why it is unable to enforce action against NHS providers. I hear what the noble Earl says about the better working relationship between Monitor and the CQC and I am sure that is right. I pay tribute to the new leadership of the CQC and to the appointment of Sir Mike Richards. However, I believe that the architecture still allows for confusion. I would like further clarification on when Monitor and the CQC can take a different view on quality issues. Perhaps we will come back to this on Report. I cannot believe that Monitor will simply accept the CQC’s judgment at face value. Surely its board will have to come to its own view on those issues. That is an area I would like to explore further.
The noble Earl was reassuring about the issue of non-foundation trusts raised by my noble friend Lord Warner. None the less, it does not feel quite like that on the ground. It does not feel as though immediate action is being taken with the many trusts that are clearly nowhere near achieving foundation trust status. I may encourage my noble friend to come back to that point. Having said that, I am grateful to the noble Earl for his comments, and I beg leave to withdraw the amendment.
Medicine: Experimental Drugs
Lord Hunt of Kings Heath Excerpts(12 years, 7 months ago)
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Earl Howe
My Lords, the noble Lord is right that the two issues are distinct. It has always been the case that a doctor can, under his or her own professional responsibility, in certain circumstances, prescribe an unlicensed medicine. However, he is also correct that clinical trials need to take place within a framework of proper ethical and organisational approval.
Lord Hunt of Kings Heath
My Lords, I refer to my health interests in the register. Will the introduction of value-based pricing inhibit or encourage early access to new medicines?
Earl Howe
My Lords, the noble Lord will have to wait, I am afraid, for the results of the current discussions that are going on with the pharmaceutical industry about what value-based pricing will look like in the end. Certainly, it is our ambition that the price of a medicine should more fairly reflect its benefit to the patient and society. Therefore, if doctors have greater confidence that those two things apply when they are made aware of the price of the medicine, we certainly hope that uptake will follow.
Care Bill [HL]
Lord Hunt of Kings Heath Excerpts(12 years, 7 months ago)
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Baroness Masham of Ilton
I would like to ask the Minister a question. I do so agree with the noble Baroness, Lady Browning, over Winterbourne; we do not want any more Winterbourne Views—and they can happen in any part of the country.
My question to the Minister is whether he would agree with me that, when it comes to crisis intervention and physical restraint techniques, all front-line staff should receive a national standard of training to deliver the best possible quality care and health services. Undermining best practice in this area is driven by three elements: a fragmented, unregulated training provider sector; procurement pressures, and commissioners’ and regulators’ roles in quality monitoring; and practice application. The people who have to be restrained are very vulnerable and, usually, mentally ill in some way. Is it really suitable for untrained people to do this job?
Lord Hunt of Kings Heath
My Lords, the noble Baroness takes us back to our debates last year on the regulation of health and social care support workers. We had some excellent discussions but, as the noble Baroness, Lady Browning, said, the Government set their face against the statutory approach without convincingly explaining to the House why they did not favour such a move. As far as I can see, the Government’s main objection appears to be cost; they are relying on better training and a voluntary register. But as the noble Baroness, Lady Greengross, pointed out, this may not be sufficient. As she says, unqualified care assistants are looking after very vulnerable people without the necessary training and support, and are being placed in a very vulnerable position. This is probably not the time to debate the loss of state-enrolled nurses, but my noble friend Lord Turnberg is absolutely right to say that the essential removal of the SEN grade has left a gap which needs to be filled.
My noble friend Lord Campbell-Savours points out that we are absolutely reliant on support workers to provide care. Many or most of them are actually very dedicated, but they are not being given sufficient tools to do the job effectively. One has to have great sympathy with the noble Baroness in her amendment.
Some noble Lords have said that it is not readily apparent why Health Education England ought to be the regulator. I certainly sympathise with that point, but no doubt the noble Baroness could easily substitute either the NMC or the HPC. We could no doubt come back to the question of which regulator it should be. The HPC has been somewhat acquisitive in past years in adding professions to its register, and would no doubt be keen to add healthcare and social care support workers to the large number of people whom it registers at the moment. As for the NMC, we understand that it has been through some difficulties in leadership and has a backlog of cases to be heard by its regulatory committees. But it has new leadership, and I am confident that it will be able to get through those problems—and, if it was chosen, it could also register health and support care assistants if that were to be required. So I do not think that there is an organisational issue in terms of difficulty in organising the regulation of support workers.
The Francis report has been mentioned by a number of noble Lords. This compelling report says:
“A voluntary register has little or no advantage for the public. Employers will not be compelled to employ only those on the register although they could be incentivised to do so”.
It concludes:
“It is not generally those who would seek voluntary registration who are the concern. It is those who will or would not seek voluntary registration but are still able to obtain employment who will be in contact with vulnerable patients”,
and those patients may not be appropriately protected. The Francis report says that this,
“need not be costly and can be self-financing”.
Amendments 23 and 23A, which we are going to come to, are very helpful but they do not do the job of regulation. Does the noble Earl think that the Government should reconsider their position in the light of the Francis report and of today’s debate?
Earl Howe
My Lords, like my noble friend Lady Cumberlege, I pay tribute to the noble Baroness, Lady Greengross, for her very carefully crafted amendment. It seeks to extend compulsory statutory regulation to healthcare assistants and care assistants and to make further amendments to legislation to account for this. I want first to acknowledge the crucial role played by healthcare and care support workers in the delivery of high-quality care to patients and service users throughout the country. That much is a given. The vast majority of workers give the very highest quality of care and are relied on and valued for the way they improve people’s lives. However, we have all seen evidence that a minority let patients down. This is a cause for concern and it is right that there is discussion about how we can ensure consistent, high standards of care.
My noble friend Lady Cumberlege made some very compelling points on the terms of the amendment but on the wider issue of principle the Government do not believe that the case for regulation is proven. Compulsory statutory regulation is not, of itself, an effective way to assure the quality of care by these workers and it can detract from the essential responsibility of employers to ensure that any person they appoint is suitably trained and competent for the role.
There are already existing tiers of regulation that protect service users, including the standards set by the Care Quality Commission and the Disclosure and Barring Service. We also need to be clear that professional regulation is not a panacea. It is no substitute for good leadership at every level and proper management of services. It can also constrain innovation and the availability of services. Experience clearly demonstrates that a small number of those workers who are subject to compulsory statutory regulation from time to time fail to ensure that their practice is up to date and delivered to the standard that we expect. In these circumstances it is too often the case that regulation can react only after the event.
The placing of hundreds of thousands of individuals on a list would not, of itself, ensure that we never again see the appalling failings in care highlighted by the Francis report into Mid Staffordshire or, indeed, Winterbourne View. Strong and effective leadership of the workforce is where the focus for improvement should lie. Employers and managers who are closest to the point of care must take responsibility for ensuring standards.
We also recognise that we need to facilitate employers to appropriately employ, delegate to and supervise health and social care assistants. To this end, as I have previously mentioned, we commissioned Skills for Health and Skills for Care to develop a code of conduct and minimum training standards for these groups in England.
In addition, we have announced the Cavendish review to consider what can be done to ensure that all people using services are treated with care and compassion by healthcare and care assistants in NHS and social care settings. The Nursing and Care Quality Forum has been established to help all those involved in providing nursing and care in all care settings to deliver the fundamental elements of good care and achieve their ambition of providing the very highest quality of care. That is in part an answer to the point made very powerfully by the noble Baroness, Lady Masham.
The noble Lord, Lord Hunt, suggested that these workers are not being given the tools to upskill themselves. We want to ensure that all healthcare assistants provide safe, effective and compassionate care, and we have already announced a number of measures to support this, including a £13 million innovation fund for the training and education of unregulated health professionals, the publication of a code of conduct and minimum training standards for healthcare and care assistants, and a review of induction training by the CQC. This is work in progress.
Having made these points, I want to reassure in particular the noble Baroness, Lady Greengross, that we have an open mind as to the range of measures that need to be put in place. However, before we can take a rounded view of what those measures should be, we need to take account of the recommendations that flow from the Cavendish review. I suggest to the noble Baroness that that is the most sensible approach.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl for giving way, but the terms of reference of the Cavendish review do not cover the regulation of healthcare support workers.
Earl Howe
No, the terms of reference encompass the core concern of the noble Baroness, Lady Greengross, which is the competence and skills of this sector of the workforce. That gets to the heart of the concerns of my noble friend Lady Browning around safety and the rest. The Cavendish review will point the way to a number of ideas that can move us in a positive direction.
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“( ) HEE has a responsibility to ensure that its duties under this section are also extended to the Local Education and Training Boards.”
Lord Hunt of Kings Heath
My Lords, I wish to make sure that the House is aware of my interest as chair of a foundation trust and as a consultant and trainer with Cumberlege Connections. This group concerns the objectives and priorities established for Health Education England in Clause 87 and that of the LETBs as set out in Clauses 90 to 93. My Amendments 22, 52 and Clause 90 stand part really go to the heart of the relationship between HEE and the LETBs. Past experience indicates that unless one has strong leadership at a national level on workforce issues, one can find that decisions are taken locally, without national consequences being thought through. In the past this has led to an unfortunate reduction in training commissions despite national exhortations not to do so. I want to avoid that happening with Health Education England. I appreciate that under Clause 90, LETBs are appointed by HEE and, I suppose, exercise functions on behalf of HEE. However, I would like to see it explicitly stated in the clause that LETBs will come under the firm direction of Health Education England.
I have to acknowledge that I have been taken to task for my amendments by the Foundation Trust Network for undermining local provider autonomy. I stand corrected. I sympathise, and understand that LETBs must have room to breathe and innovate. However, ultimately, the integrity of a national strategy must be maintained. I hope that the noble Earl’s response on this and, on the ability of HEE to amend the training plans of LETBs if they are considered to fall short, will be positive.
I turn to Clause 92 and my Amendment 47 on the co-operation required between LETBs and local providers. The clause ensures that commissioners must require providers to co-operate with the LETB in planning the provision of, and in providing, the education and training for healthcare workers. Who could disagree with the need for NHS trusts, foundation trusts and other providers to be called to co-operate with the LETBs. But why is this being done through the commissioning process?
I have frequently listened to Ministers, when asked to intervene in the NHS, say that it is a matter for commissioners. I do not want to argue the ideology of commissioning and providing, but I wonder whether that is the right approach in this case. If one thinks of the challenges facing clinical commissioning groups, with small staffs and little experience, can it be expected that they can devote time to ensuring that providers co-operate with each other and the LETBs over education and training? Realistically, I suspect they will have very little time indeed. Therefore, as a minimum the HEE should be required to give guidance on how commissioners are to undertake that responsibility. More substantively, why not lay a direct requirement in the Bill on NHS foundation trusts and trusts on the face of the Bill to co-operate with the LETBs? That would be a signal of intent that NHS bodies could not ignore. I hope the noble Earl might be prepared to give that some consideration.
My third and fourth amendments in the group concern the organisations that LETBs must involve in preparing their education and training plan as set out in Clause 93(4). Overall, this clause is welcome, but it could be improved by my Amendment 49, which adds local authorities to the list. I am sure that the noble Earl will argue that this is covered by Clause 93(4)(c), specifying that health and well-being boards must be involved. However, the importance of these plans goes wider than that. I am sure that the local authority in general in the area of the LETB would have much to offer.
Similarly, Amendment 51 seeks to have patients and carers involved. With all the debate about whether professionals trained to work in the health service are really ready to give clinical care—I go back to the debate we had recently about healthcare support workers—surely patients should have a place round the table, where decisions that have a crucial bearing on patient outcomes are made. Very similar amendments and arguments can be made in support of the amendments of my noble friend Lord Turnberg and the noble Lord, Lord Patel, which I support. However, I hope that the noble Earl will be able to come back positively on the need of patients or carers to have a place and be involved when the training plans of the LETB are being considered. I beg to move.
Earl Howe
My Lords, I would rather have a creative tension than a disconnect. If we get this right the tension will be there but it will be mutually reinforcing. You will have accountabilities running in both directions, essentially, from the national to the local and from the local to the national. In the past this has been a notoriously difficult area to get right. We hope and believe that the structure we are putting in place, in which the LETBs are committees of the national body but which have their own autonomy to a certain degree, will ensure that the tension that the noble Lord referred to really is creative, rather than the reverse.
Lord Hunt of Kings Heath
My Lords, that was a very useful exchange. I do not disagree with this architecture, in which national leadership comes from HEE but considerable autonomy is given to LETBs. When looking back at the history of the NHS I remain concerned, as does my noble friend, about failure to implement national strategies in relation to the workforce. This is because decisions are being taken locally which do not fit into the national strategy, particularly over training commissions. This afternoon the noble Earl said that HEE has enough powers to intervene if that were to happen. I think the question is whether HEE has enough national leadership and confidence to actually ensure that a national strategy is implemented. Of course, we will have to see.
On membership, I note the noble Earl’s statement about the number of different professional groups that will have to be covered by LETBs, which is why postgraduate deans are not listed on the face of the Bill. I think that my noble friend really was persuasive on this point. Doctors may not be the only profession, but they are a very important profession. I would have thought it quite extraordinary not to have a postgraduate dean among those around the table of the LETB. Equally, I do not think that the patient advisory forum is sufficient at national level. Considering the NHS record over the last few years, one of the areas causing most concern has been whether trained staff are fit for purpose when it comes to clinical areas. To have a representative of a patient or carer around the table at a LETB would have been very important. However, this has been a good debate, and I beg leave to withdraw my amendment.
Baroness Cumberlege
My Lords, I support these amendments on mandatory training. I know that the noble Baroness, Lady Emerton, has fought and fought for this. I served with her on the United Kingdom central council for nursing, midwifery and whatever it was. She pioneered the whole idea of improving nurse training, and it was very successful.
To follow on from the noble Baroness, Lady Hollins, it is interesting that we now have two different parts to the arguments. One concerns the benefit to patients and the public, while the other concerns the benefit to the workers themselves, which I thought was a very interesting angle. It was Terry Leahy who said that he built his empire just by ensuring that all who worked for him felt good about themselves, and I thought that that was very interesting.
I am concerned about how the amendments are fashioned because I am not quite sure what we are talking about. Perhaps the noble Baroness or the noble Lord, Lord Patel, will clarify that for me. We talked about healthcare support workers, and I understand that such workers predominantly work in the NHS. However, subsection (2) of the proposed new clause refers to,
“a health or care support worker”.
I am not sure what a care support worker is, as opposed to a healthcare support worker. Does the support worker work, as the noble Baroness, Lady Hollins, said, in people’s homes? Do they work in residential care? Are they covered by this or not?
The noble Baroness made another point, which I was also going to raise and on which I would like some clarification: what about the people who work for others who need care, through direct payments or personal budgets? Will this rule out those volunteers who often come in and sit with someone, who may do some minor tasks and may even do some relatively nursing-style tasks, such as putting in eye drops, which a member of the family would do? I should like to clarify who we are talking about.
Lord Hunt of Kings Heath
My Lords, like my noble friend Lord Campbell-Savours, I remain puzzled by the Government’s approach. I am grateful to the noble Baroness, Lady Emerton, for setting out a number of persuasive arguments for why there ought to be mandatory training for health and care support workers. There seems to be a general consensus around the House and no doubt the Minister will agree with it. My reason for supporting the amendment is that mandatory training is clearly very important, but it is inevitable that if you have mandatory training you have regulation; the two run together. Those who are proposing these amendments ought to recognise that there is an inevitability that if you have training then you must have a list of people who are trained; action has to be taken against those people who have been trained but are then found to be unsafe in dealing with vulnerable people; and there has to be a way of removing them from the list of those who have been trained that has been published. If you go down this route, one way or another you are clearly signing up to mandatory regulation, and a jolly good thing too.
Amendment 23A puts forward an eminently sensible suggestion for healthcare support workers to be certified to show that they have been trained in basic standards, with employers to register individuals who hold such certificates. We need to go back to the Francis report. Mr Francis is widely reported to be disappointed with the Government’s response to his report, and it is not hard to see why. His report commented on the absence of minimum standards in training and competence. This is compounded by huge variations in the approach of employers to job specifications, supervision and training requirements. That is why my noble friend Lord Campbell-Savours has come across so many instances of poor-quality healthcare support.
The Prime Minister’s Commission on the Future of Nursing and Midwifery noted that training for support workers was very variable and recommended that they should be better trained. In response, as the noble Earl told us earlier, the Government have commissioned Skills for Health and Skills for Care to work together to develop a code of conduct and minimum induction and training standards. We now know from the mandate issued by the Secretary of State to Health Education England that it is obliged to establish minimum training standards for healthcare assistants by spring 2014. At this point, I ask the noble Earl: how far does that go? Will it be mandatory for all entrants to the role of healthcare assistant to undertake such training? If that is so, will this extend to care assistants? What about existing health and care support workers? Will this training extend to them, or will it apply only to new people coming into the healthcare profession?
Under the proposals, how will employers know if their support workers have undertaken the minimum standard of training? Will a nationally recognised certificate be issued? Will a national list be established, indicating those who have undertaken such training? If there is not a list, does that not leave a big burden on employers seeking to check whether prospective staff have undertaken the minimum training requirement under the mandate? I come back to the point I made at the beginning: if a list is established, would that, in essence, not amount to a register? If there is such a list or register and it becomes clear that a support worker is unsuitable to care for vulnerable people, is there a way in which an organisation or employer could then apply to have such an individual removed from the list of people who have received the minimum level of training?
Having a certificate showing that someone has achieved a minimum level of training will be generally regarded as a certificate of an ability to practise. If there is such a certificate, there must be a way to remove that certificate if people are found to be wanting. In effect, once one begins to lay down minimum standards and to specify mandatory training, will there not be an inevitable step towards regulation? Amendment 23A poses those questions to the noble Earl. I hope that he will answer sympathetically.
Earl Howe
My Lords, I first thank the noble Baroness, Lady Emerton, for an interesting set of proposals and I am grateful for her thoughtful introductory remarks. I agree that ensuring the capability of the health and care support workforce is vital to delivering high-quality care to patients and service users across both health and social care settings. The issue is how we achieve this. Key requirements for delivering high-quality care can best be achieved by providers having the right processes in place to ensure they have the right staff with the right skills and the right training to deliver the right care in the right way to patients and service users.
The idea of statutory requirements can seem an attractive means of ensuring patient safety, yet Robert Francis’s report demonstrates amply that this in itself does not prevent poor care. I confess that I was a little surprised by the vehement support of the noble Lord, Lord Hunt, for the idea of statutory regulation because it was an idea that his Government resisted for some time. I suggest that they resisted it for a number of reasons and they came to the conclusion that it is not as self-evident as some like to make out. That is certainly this Government’s position. This is not, as the noble Lord, Lord Campbell-Savours, suggested, a laissez-faire attitude on the part of the Government. As we made clear in Patients First and Foremost, the initial response to the Francis inquiry, the Chief Inspector of Hospitals will ensure that all hospitals act to make sure that all healthcare assistants are properly trained and inducted before they care for people. I suggest that this is an important step forward.
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Lord Hunt of Kings Heath
My Lords, we now come to the tariffs to be imposed in respect of education and training. Clause 95 establishes a tariff-based system for funding clinical education and training, whereby providers receive the same payment for the same activity. This is intended to enable a national approach to the funding of clinical payments and to provide for equality of treatment between different providers. What the clause does not do is to provide for equality of treatment between the public and private sectors. The noble Earl will be aware of Monitor’s fair playing field review that looked at a number of different activities and the impact on different providers, including public sector providers, private sector providers and the third sector. On education and training it remarked:
“Many stakeholders voiced concern that the private or charitable sectors are able to employ clinical staff without facing the cost of training them”.
It has been reported recently that surveys show an increase in the use of the private sector by the NHS in recent years and enforced marketisation. The Section 75 regulations are likely to increase that. The question that I put to the Minister is, if the NHS is developing much more into a mixed economy, what is the provision for the private sector to contribute to education and training?
Lord Campbell-Savours
As a layman among all these very professional people, I raise a very simple point. Returning to the private care home paying workers something like £7 an hour, I presume that that care home, if it so wished, could use the LETB.
Lord Hunt of Kings Heath
There are various definitions relating to LETBs. For instance, Clause 90(3) says:
“In carrying out its main function, an LETB must represent the interests of all the persons who provide health services in the area for which the LETB is appointed”.
However, the general interpretation on page 89 defines not “health services” but rather “the health service” as,
“the comprehensive health service in England continued under section 1(1) of the National Health Service Act 2006”.
My question is: does “health services” in Clause 90 equate to “the health service” in Clause 110, or is “health services” in Clause 90 a wider interpretation that embraces the argument of my noble friend Lord Campbell-Savours?
Earl Howe
It may be convenient for the Committee if I take together the questions of the noble Lords, Lord Campbell-Savours and Lord Hunt, because the noble Lord, Lord Hunt, asked me about the role of the independent sector in participating in training and indeed in funding it. Perhaps I may clarify that.
The Health and Social Care Act 2012 placed a duty on the Secretary of State to ensure an effective education and training system, as I mentioned earlier. The Act also placed a duty on commissioners of health services to ensure that providers support the Secretary of State in this duty when contracting with them. The Government have already put into place measures to deliver the Secretary of State’s education and training duty by amending the commissioning contracts and supporting regulations for the delivery of services, so they now require co-operation on education and training. This means that all providers of NHS services are expected to co-operate and, where appropriate, this co-operation will involve them providing education and training.
Earl Howe
The answer is twofold. First, the Care Quality Commission inspects every care home to a uniform standard. One of its duties is to ensure that the staff in a care home are sufficiently capable and trained to deliver care in the right way to the patients and service users who live there, taking into account the acuity of need of those people. Secondly, as the noble Lord may be aware, the Government have proposed that a system of star ratings should be reintroduced for both healthcare settings and adult social care settings. In that way the general public may have a much closer and more detailed sense of the quality of care provided in the care home, as assessed by the Care Quality Commission. Again, this is work in progress. The Care Quality Commission is working out its methodologies for delivering those star ratings, but if we get this right, I believe it will take us several steps forward in transparency of quality and the ability of members of the public to choose, in a much more meaningful way, the setting that they wish to see either themselves or their families benefiting from.
Lord Hunt of Kings Heath
My Lords, that has been extremely useful. The intervention of my noble friend Lord Campbell-Savours has been particularly useful. Reading Clause 86 (5) together with Clause 93 and the interpretation in Clause 110, it becomes clear that many nursing homes will receive some funding from the NHS in providing continuing healthcare for some residents. That seems to me to be very helpful indeed because, given that there is a great deal of concern about the quality of staff in nursing homes and the training of those staff, it gives local education and training boards a clear remit to concern themselves with the staff in a lot of nursing homes in their area. I hope that it will be possible for a message to be sent to Health Education England from this debate that, if it is looking at the most vulnerable areas in terms of vulnerable people, that ought to be where the priority should be. My noble friend has teased out a very important indicator of the way in which LETBs should work in future. I hope we will see in their plans that a major effort will be devoted to the staff in those homes.
On the more general question, I noted that the Minister had been urged to be cautious by various bodies in relation to whether there should be a levy on private sector providers. It is a bit rich of the Future Forum to worry about the third sector contribution since it is the Future Forum that has tried to open the door to a competitive market in the NHS. The third sector and Sir Stephen Bubb cannot have it all ways. If he wants to have a competitive market, as he seems to, then the third sector can jolly well make a contribution alongside the NHS. They cannot have it both ways.
Earl Howe
My Lords, I hear what the noble Lord has said on this. In practice, as he knows, most education and training take place in the public sector, but we expect Health Education England and the LETBs to seek advice from a range of stakeholders. Indeed, HEE has reinforced the importance of this in the appointment criteria that it has set for LETBs which state that they should demonstrate meaningful collaborative working relationships with stakeholders, including third and independent sector providers. This will help to establish stronger links with the independent sector so that it can deliver clinical placements and perhaps also postgraduate training programmes where appropriate.
Earl Howe
My Lords, I beg to move Amendment 53, and at this point it will be convenient to consider government Amendments 54 to 57 as well.
The importance of balancing a person’s right to confidentiality with the benefits of using information to improve the current and future health and care of the population cannot be underestimated. The NHS constitution sets out a number of rights and commitments in this regard.
Section 251 of the NHS Act 2006 provides the Secretary of State with a power to make regulations that modify the common law obligations of confidentiality so as to allow researchers, public health staff and other medical practitioners to access information where there is no reasonably practicable way of obtaining consent to use such information for the purposes of medical research; that is, in the interest of improving patient care or in the public interest.
The Health Service (Control of Patient Information) Regulations 2002 made under Section 251 of the NHS Act make provision for public health surveillance and risk management, work associated with cancer registration and approvals for the processing of confidential patient information for medical purposes in certain circumstances, provided that the processing has been approved by the Secretary of State.
These amendments provide continuity for the functions of advising on the approval of processing of confidential patient information for medical purposes, other than direct patient care. These functions were previously carried out by the national information governance board and its ethics and confidentiality committee. The special health authority has been directed to undertake these functions since 1 April this year, and so the provisions would ensure continuity.
I turn to the detail of this group of amendments. The amendments would require the Health Research Authority to appoint an independent committee to provide advice on applications to process confidential patient information. The committee would advise on approvals to process confidential patient information for medical research purposes and for other medical purposes. As the Bill is currently drafted, the Health Research Authority would have the power to appoint such a committee under its proposed functions in Schedule 7 to the Bill, but this would be discretionary.
This group of amendments would ensure that such a committee is established and that it is independent. This is important to ensure that the arrangements that are currently in place will continue, maintaining public confidence in the decisions made. In the interests of consistency across the system, these amendments would require a single, independent committee to advise both the Health Research Authority itself on approval for medical research purposes, and the Secretary of State on all other approvals for medical purposes.
The Health Research Authority special health authority has established an independent committee, known as the Confidentiality Advisory Group, to advise the existing Health Research Authority and the Secretary of State on approvals. The provision of transparent, expert and independent advice to support approvals for processing of confidential patient information is vital. It protects and promotes the interests of the patient while facilitating the appropriate use of confidential patient information beyond direct patient care. It ensures that each application for approval is carefully considered and that there is consistent, expert advice to inform approval decisions.
I hope noble Lords will accept that these amendments will ensure that there continues to be independent advice on applications to process confidential patient information for medical purposes. I beg to move.
Lord Hunt of Kings Heath
My Lords, I am sure that the amendments will be welcome, and that access to confidential patient information needs to be accompanied by full safeguards for the protection of individual patient privacy. However, will the noble Earl also confirm the importance of access to this information for the purposes of legitimate research? Can he also confirm that by transferring these functions to the HRA, we can look forward to a more transparent, consistent and streamlined process in the future?
Earl Howe
My Lords, as I indicated, we have always needed to strike a balance—reflected in the 2002 regulations which the noble Lord brought forward in that year—between protecting the rights of the individual and ensuring that ethical approved research can take place using confidential patient data only where appropriate. I agree with the noble Lord that we should not place any undue barriers in the way of research, but there are clear rules around this which we need to honour and protect. We will be reaching a group of amendments around the issue of transparency, and if the noble Lord will allow it, I will reserve my remarks on that until we reach that group of amendments.
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Lord Hunt of Kings Heath
My Lords, it is a great pleasure to open the Committee stage debates on the Care Bill. Schedule 5 relates to the establishment of Health Education England as a non-departmental public body. Schedule 5 is concerned with the membership of Health Education England and other matters to do with its establishment. As this is the start of Committee stage, I declare an interest as chair of an NHS foundation trust, and as a consultant and trainer with Cumberlege Connections.
The education and training of staff in the National Health Service is of course a critical responsibility, on which patients depend for good outcomes of care. The UK has traditionally enjoyed a very high reputation for the quality of our training and educational institutions and for the standing of the professional staff who come into the National Health Service. However, we should also acknowledge that there are a number of challenges facing the UK in ensuring that we continue to produce the right kind of people, in the right specialties and in the right numbers, taking into account the long-term challenges we face, not least that of an ageing population.
We received lots of briefings for this part of the Bill, for which I am most grateful. I was particularly struck by the briefing I received from the Royal College of Physicians, which points to trends in medical education and training. On demography, it points out that by 2033 there will be 3.2 million people above the age of 85, with the prevalence of dementia expected to double. On social trends, people have more choice and higher expectations. On efficiency, the economy of course will shape services substantially and we know that, in the short term at least, the NHS faces unprecedented austerity.
While the Royal College of Physicians believes that many elements of the current training structure are excellent, there is a need for change too. Many more physicians must train in internal medicine to meet the new needs of patients across hospitals and community services. There is an emerging view that too many consultants specialise too soon and that there is a need to focus more on general physician consultants if we are to meet some of the problems that hospitals are facing. A&E is a symptom of the need for hospitals, in particular, to change the way they are often organised in order to recognise that their key client group are frail, older people who probably need the attention of generalist physicians as much as speciality doctors. The RCP points out that the doctor-patient relationship is evolving and that this needs to be reflected during training. It says that there should be more flexibility for time out of training and career progression between different grades which meets the changing needs of the health service.
Every royal college and many trade unions and patient groups have made similar comments about the need to look at the training and education of our professionals. We know that there are formidable challenges with regard to nurse education. The Francis inquiry identified a number of these. There is a real worry that newly-qualified nurses are not well prepared to take on full nursing responsibilities. The excellent independent report of the noble Lord, Lord Willis, commissioned by the RCN, contains some very important messages for us in our debates. There is a debate among the public and in Parliament about whether the caring aspect of nursing has sometimes been neglected. There is also the issue of whether healthcare support workers lack mandatory training and registration. I have no doubt that we will also debate those matters.
The connection between this and Schedule 5 is that Health Education England will be faced with many interesting and difficult issues. I can say to the noble Earl that we support the establishment of HEE in statute and I am very glad that Sir Keith Pearson has been appointed as chair of that organisation. The noble Earl will know that he was previously the distinguished chair of the NHS Confederation and an NHS trust. He brings to the job a wealth of experience.
The amendments in this group are designed to enhance the ability of Health Education England to understand the pressures that the service is under in relation to staffing and to ensure that our education and training is flexible to the rapidly changing face of health and social care. There are three amendments concerning the membership of Health Education England, as set out in paragraph 2(1) of Schedule 5, which states:
“The members of HEE must include persons who have clinical expertise of a description specified in regulations”.
Amendment 1 seeks to delete that but I hasten to add that it is a probing amendment. I have no problem at all with people of clinical expertise being on the board—far from it. However, I seek assurance from the noble Earl that one of the members appointed will be a registered nurse. This relates also to Amendment 3.
I need hardly speak to the House of the importance of nursing issues to the workforce and to the work of Health Education England. I remind the noble Earl of recommendation 204 of the Francis report into Mid Staffs. It states that all NHS bodies,
“should be required to have at least one executive director who is a registered nurse, and should be encouraged to consider recruiting nurses as non-executive directors”.
I hope that the noble Earl will be able to respond positively. The nursing workforce is so important to the quality of care that it is crucial that Health Education England has nurses around the board table both on the executive and non-executive sides. Every time there is a restructuring of NHS boards, often there will be people who try to exclude nurses from those boards. They are mistaken. I do not think that boards in the NHS can do without nurses around the top table.
My noble friend Lord Turnberg will of course speak to his own amendment but I support its thrust, which is to appoint one or more members with expertise in research and one or more with expertise in medical education and training.
I also hope that recognition will be given to the needs of those staff who are not professionally registered. My Amendment 4 refers to that point. How are the needs of healthcare assistants going to be met if there are not people around HEE who understand the constraints and pressures under which they work?
Managers in the health service, many of whom are not qualified in the traditional sense of being professionally registered, have a crucial role to play. I had hoped that Health Education England would be concerned about the identification and development of those managers. I remind the noble Earl that there is a big problem in recruiting chief executives to NHS bodies, perhaps because their length of stay is almost as bad as that of football managers. That tells it own tale about the job. I hope that Health Education England will consider that it has some responsibility to look at how the managerial cadre can be developed and trained, and how they can be given some security in their jobs and reassurance about what will happen to them if they need to move on from one organisation to another.
Earl Howe
It may not surprise my noble friend to know that I asked my officials the self-same question, because I anticipated an appetite for draft regulations. I am, unfortunately, not in a position to make that promise, much as I would like to do so, because there may not be the necessary time available for the regulations to be drawn up in draft. However, I will take back the strength of my noble friend’s request and see whether there can be any reconsideration of that point.
Lord Hunt of Kings Heath
My Lords, it has been a very good debate, and I am grateful to the noble Earl and other noble Lords for taking part. It is the role of noble Lords always to ask the Government for draft regulations but, alas, I fear that we may not see them. If we cannot, perhaps we could at least get a sense of instructions that might be given on policy direction.
First, let me say that the Government’s reflection on the Joint Committee’s recommendation with regard to clinical expertise, and the change that has been made, is welcome. I listened with care to the noble Earl when he said that the needs of Health Education England and the education and training of staff may change over time, which is why that is best left to regulation. That makes sense, but I cannot believe that there will ever be a time when research and nurse representation will not be important. I ask the noble Earl to give that further consideration.
I will just reflect on the comment of the noble Baroness, Lady Emerton, that this has been a consistent theme of restructurings over the years. The noble Baroness, Lady Cumberlege, and I have lived through many restructurings and they always start with the premise that there will not be a nurse on the board. Then, after argument and sometimes experience, it is discovered that you need to have a nurse. I would have thought that the Francis report, at its heart, focused a lot on nursing experience and leadership. I ask the noble Earl to give this further consideration. It would be a very visible sign that the Government are listening to this point and that they actually set out in primary legislation that a registered nurse should be appointed.
I am glad that the noble Earl picked up the point about non-registered staff and managerial staff. It is not just in the health service. In the further education sector there is a similar problem, with only a limited number of people applying to be college principals. We need to think very hard about what we can do to give greater support and encouragement to bright young people coming through so that they aspire to take on these top jobs. No one should underestimate the pressures that those leaders are under, but we really want good people. I endorse the noble Earl’s reference to clinicians. We need to encourage more clinicians to take on leadership roles.
I was very interested in the contrast between the desires of the noble Earl not to give autonomy to the board to appoint its own chief executive, but to give it autonomy when it came to the salaries of its staff. I ask for some consistency here. If the Secretary of State appoints the chair and the non-executives—which is absolutely right—he or she should then have confidence in their judgment to allow the board to appoint a chief executive.
Finally, on the intervention of the noble Baroness on integration, it might help our future debate if the noble Earl could confirm that Clause 88, on matters to which HEE must have regard and in which subsection (1)(h) refers to,
“the desirability of promoting the integration of health provision with health-related provision and care and support provision”,
answers the point that the noble Baroness raised—that in effect HEE does have to have an understanding of the needs of those providing social care because of the contribution that they can make to integrated services.
Lord Hunt of Kings Heath
My Lords, I am very grateful. Having said that, I beg leave to withdraw my amendment.
Care Bill [HL]
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Baroness Wall of New Barnet
My Lords, I, too, support Amendment 36. I just want to pick out something that the noble Earl mentioned a little while ago in response to another question from me. He mentioned the work being done by Skills for Health and Skills for Care. Certainly in the context of this amendment—which, I agree, is a probing amendment—alongside the royal colleges and the other professional bodies, the work that Skills for Health and Skills for Care are doing is hugely important. Can the noble Earl enlighten me on what relationship Health Education England will have with those bodies? For instance, the noble Lord just referred to what the future looks like and what Skills for Health in particular is doing alongside Skills for Care. It is looking at what provisions there are for apprenticeships inside the health service, which is hugely important and allows people to develop from smaller roles to bigger roles over time. I wonder how, in the scheme of things, that relationship exists, how close it is and what influence Skills for Health and Skills for Care have, so that they are not working in opposition but are working integrally with what HEE is doing.
Lord Hunt of Kings Heath
My Lords, I have a few amendments in this group. It is an important group because it concerns not just the functions of Health Education England and its duties to co-operate but also, of course, the membership of LETBs, the local committees of HEE.
It is very important that HEE works with NHS bodies that have expertise in education, training and regulation, so I am very happy to support my noble friend’s Amendments 9, 18 and 34, and Amendments 15 and 36 in the name of the noble Lord, Lord Willis. I would add two organisations from which HEE must seek representations: the CQC and Monitor. I imagine the noble Earl will say that they are implicit in the generic list of bodies in Clause 89(2). However, it would be good to hear a little bit about how the noble Earl expects HEE to work with the two core regulators for the health service, the CQC and Monitor. In a sense, the CQC will, on a very regular basis, be picking up issues to do with staffing and staffing levels. Equally, Monitor will be concerned with financial issues. Of course, the two sometimes do not run easily together, so it is very important that HEE has very close contact with those two bodies.
As regards Clause 91 and LETBs, which are essentially committees of HEE charged with ensuring sufficient skilled healthcare workers in the area of the LETB, the Bill makes clear that in carrying out its main functions, the LETB must represent the interests of all persons,
“who provide health services in the area for which the LETB is appointed”.
I have already referred to my interest as chair of a foundation trust, and I very much welcome the architecture in which it is clear that, at the local level, the people in the driving seat should be the people who provide services. In the past, people running hospitals and other services have been divorced from decisions about training commissions. That is one of the reasons why I believe there has been such a problem with the ability of people coming out of universities and other education institutions to practise when they get into the field. Having the people who provide services round the table is a very important development.
Of course, it is also important that other people are involved in those discussions. In the architecture of the Bill, there are two categories of membership provisions. In Clause 91(3)(a) and (3)(b), it is clear that LETBs must include,
“persons who provide health services in the area”,
and,
“persons who have clinical expertise”.
It is consistent with the provisions in relation to Health Education England. Then in Clause 91(5), people involved in education may be appointed to a LETB—but, by implication, if they may be they do not have to be. My Amendments 40 and 42 to 46 really seek to ensure that LETBs have a broad-based membership. Surely, it should be mandatory to have the involvement of education providers and health workers who are not professionally registered. My noble friend Lady Wall made that point very well indeed.
Also, where are the representatives of patients and carers? After all, they understand the output of the workforce. Surely, they ought to have a place around the table as well when it comes to these decisions about training commissions: where they are placed, what the demands are and what the monitoring is. Again, I would replicate the argument about nurses that we had on the membership of HEE. In some sense, we could have grouped those amendments together because it is the same argument: that around the table of the LETB, you must have some senior nurses when so many of the discussions of the LETB will be about the quality of nurse training.
What about the health and well-being board? We have heard earlier debates. In fact, in the House of Commons Select Committee this morning, when witnesses were giving presentations about what has happened in emergency care, the representative of the LGA made a very strong point about the potential role of health and well-being boards, which are concerned not just with public health but with how well the whole system is integrated. I very much agree with that, so I would have thought that a LETB would be well advised to have the chairmen of relevant health and well-being boards around the table to discuss issues of staffing. I hope that the noble Earl will give me some reassurance that in establishing LETBs as provider organisations, something with which I certainly agree, there will be room for these other interests to be represented as well.
Earl Howe
My Lords, Amendments 9, 18 and 34 seek to require Health Education England to seek the advice of regulatory bodies and royal colleges in the exercise of its functions. Similarly, Amendment 36 seeks to amend Clause 89(3) to require Health Education England to seek advice from all the medical royal colleges. Amendment 15 seeks to amend Clause 85 to require HEE to seek representations from relevant organisations to define sufficient workforce numbers and the appropriate skills mix when carrying out its duty.
The education and training landscape is multifaceted. Many organisations have an interest in the development of health professionals, ranging from local employers in the NHS through to national organisations such as the professional regulators, including the Nursing and Midwifery Council, and professional bodies such as the medical royal colleges and those supporting other professions. To carry out its role effectively, Health Education England and the local education and training boards need to tap into all this knowledge and expertise. These bodies have crucial responsibilities in setting professional standards, shaping curricula and driving forward improvements in the quality of education and training. Health Education England simply has to work closely with them to deliver its functions.
The medical royal colleges in particular play an essential role in supporting the development of the medical profession, shaping curricula and the development of training programmes, supervising training, examining trainees to ensure the highest professional standards, promoting and supporting research, supporting audit and evaluation of clinical effectiveness, and generally providing support and advice for doctors at all stages of their careers. So I can reassure the Committee that Health Education England is already required to work with the professional regulators and medical royal colleges to obtain their advice on the exercise of its functions.
Clause 89 requires Health Education England to obtain advice on the exercise of its functions. Clause 89(2) requires HEE to seek to ensure that it receives representations from bodies which regulate healthcare workers and persons who provide, or contribute to the provision of, education and training for healthcare workers. This includes universities, professional bodies and the medical royal colleges.
The noble Lord will be pleased to hear that Health Education England is already working with the professional regulators and medical royal colleges. When he gave evidence to the Joint Committee that scrutinised the draft Bill, Professor Ian Cumming, the Chief Executive of HEE, was very clear that he saw the professional regulators and royal colleges as partners in developing the next generation of staff. Professor Peter Rubin, the chair of the GMC, gave evidence in the same session and reinforced that view, reassuring the committee that the GMC has a very good working relationship with Health Education England.
HEE is not starting from scratch in building these relationships. It is building on the good work previously done by Medical Education England and others to strengthen engagement and partnership-working with the professions. As I mentioned earlier, the HEE special health authority has established profession-specific advisory groups, involving employers and key partners including national regulatory and professional bodies. These will look at profession-specific workforce development across medicine, dentistry, nursing and midwifery, the allied health professions, pharmacy and healthcare science. They will each have a patient representative and be co-chaired by Health Education England and the professional lead in the relevant field.
In addition to having profession-specific advisory groups, Health Education England is establishing a multi-professional advisory group to bring all professions together to look at cross cutting issues. I hope that is a positive piece of information for the noble Baroness, Lady Emerton, in particular. I hope that the noble Lord, Lord Hunt, will be pleased that it is also setting up a patient forum to ensure patients and service users can engage in education and training and inform work in that area.
Lord Hunt of Kings Heath
I am very grateful to the noble Earl on that point. Is there a case for replicating that at local level, through the LETBs?
Earl Howe
Certainly, I do. I am happy to take that idea away, and if I can give him any further information during the course of our debates I will. Equally, the LETBs have strongly established connections with professional regulators and professional bodies. For example, the postgraduate medical and dental deans, who are now an integral part of the LETBs, work very closely with the GMC and medical royal colleges in the management and quality assurance of training for junior doctors. I hope that those remarks will reassure noble Lords sufficiently for them not to press the relevant amendments.
In reply to my noble friend Lord Willis, who expressed concern about the way the Explanatory Notes were framed, it is important to look at the entire context of the passage he quoted. The words “such as” appear in that passage before “the medical Royal Colleges”, so it is not meant to denote an exclusive reference to the medical royal colleges; it is very much trying to say that the professional bodies in general will be relevant here.
Amendment 35, tabled by the noble Lord, Lord Hunt, and the noble Baroness, Lady Wheeler, seeks to amend Clause 89 to require HEE to seek advice from the Care Quality Commission and Monitor. It is very important that Health Education England works closely with those two bodies. The Care Quality Commission plays an important role in assessing the quality of healthcare services, and in so doing it assesses their ability to deliver services safely and effectively. In doing so, it will consider whether healthcare providers have suitably skilled staff and in the right numbers. It will need to work closely with Health Education England to share findings and evidence to support improvements in education and training. Health Education England will also be able to share information on the effectiveness of providers in supporting clinical placements and training programmes to support the Care Quality Commission in its role.
HEE and Monitor will work closely together to ensure the financial stability of the health system. This will include working together on the reform of education and training funding and the development of education and training tariffs. To reflect the importance of these relationships, the Bill places a clear and reciprocal duty on Health Education England to co-operate with both the Care Quality Commission and Monitor. I hope noble Lords will feel reassured by that and will be able to withdraw this amendment.
Lord Hunt of Kings Heath
My Lords, we come to a series of clauses that deal with the functions and priorities of HEE. I have a number of amendments in this group. The first is Amendment 11. Clause 84(6) states:
“HEE may, with the consent of the Secretary of State, carry out other activities relating to … education and training for health care workers”.
I am curious to know why the Secretary of State has to give his consent. Does not the mandate in Clause 87 give the Secretary of State enough oversight, without the micromanagement that this part of Clause 84 seems to imply?
Amendment 12A relates to the duty of HEE to ensure that there are sufficient numbers of persons with skills and training. What does “sufficient” mean? Does it mean an equilibrium of supply and demand, or do the Government want an oversupply? This is a matter that the Select Committee looked into, and about which a number of royal colleges are concerned. They take the view that it takes so long for doctors to come through the training grades that one wants an equilibrium rather than a situation where people who have committed themselves to 15 years’ training find that there is no work for them at the end of it. Perhaps the noble Earl might take up that matter with me in writing.
Amendment 14 asks HEE to,
“have regard to any official guidance on staffing numbers and skills mix”.
We will come back to this issue. The Minister will know that the Francis report recommended that NICE essentially should produce benchmarking measures for minimum staff numbers and the required skills mix, including for the number of nurses on wards. It is too late to have a debate on issues to do with nursing staff ratios, but it would be good to know whether the Government will take forward recommendations 22 and 23, because that work will be very relevant to HEE’s own work on the number of staff required in future.
Amendment 19 relates to Clause 86 and deals with quality improvement in education and training. All I ask from the noble Earl is a recognition that in future we will need to revisit the curricula of the universities to make sure that when doctors, nurses and other practitioners leave those universities and are ready to go into employment, they will have some practical-based training from having undertaken clinical duties. I am not convinced that the bodies that set the curriculum have got it right yet. Whenever challenged on these issues, they always claim that everything is hunky-dory and that we should not worry and yet there is a complete loss of public confidence in those training programmes. I do hope that HEE is going to be able to give a kick to those bodies that are concerned with the curricula and those education institutions to ensure that people are ready to practise when they are given their ticket to go into the health service.
On Clause 87, which concerns the objectives, priorities and outcomes of the HEE, I have another series of amendments. I want to tease out the Government’s recognition that, although in the construct of the Bill HEE will have an annual plan, it will also be required to look three years ahead. I wonder whether that is long enough. The argument that has been put to me by a number of organisations is that the time between the commissioning of a training place and that person practising in the health service can be many years. One of the questions is whether it would be better if HEE had to develop five and 10-year plans and match those with the demographic and the demand pressures on the health service. It would be helpful if the noble Earl would recognise the need for much longer term planning.
Clause 88 sets out important matters to which HEE has to have regard. In Amendment 28 I ask whether HEE will have to have regard to a need for equality of funding across England and consistency in education and training opportunities. Given the mismatch between a population and the education and training facilities available, will HEE have a duty to balance where those resources go?
On Amendment 29, will the noble Earl confirm that specialist training-place issues will be dealt with nationally? I need hardly remind him of the sensitivity of this in relation to junior doctor training. I wonder whether it is good enough to leave it to local LETBs to decide. I do think that some national provision and direction is required.
Amendment 30 concerns HEE’s relationship with other countries of the UK. There is a reference to the need for HEE to undertake duties in relation to the devolved Administrations. Surely much more is required. We are talking about a UK health service. Scotland definitely trains more people than is required for the Scottish health service. The same may be the case in Wales which has big problems in attracting junior doctors. There needs to be a UK-wide view of education and training and I hope that the HEE has both the remit and the encouragement of Ministers to work across those borders.
Amendment 32A covers the matters to which HEE must have regard. I have put down an amendment to ask HEE to give specific focus to arrangements for end-of-life care. The noble Earl has taken part in a number of debates on the Liverpool care pathway which have served to raise issues not so much about the policy behind the pathway, although I know that a review is being undertaken, but more about the way in which that has been interpreted by some organisations. It suggests that more is required in relation to the training of staff in end-of-life care. I am sure that in Part 1 we will come back to the issue of social care provision for end-of-life care but it would helpful if the noble Earl could reassure me that this one of the matters that HEE may look at. I beg to move.
Lord Rix
My Lords, I wish to speak to Amendment 24, which explores the benefits of placing a duty on the Secretary of State to consult on the objectives and priorities of Health Education England. In particular, I wish to explore how the Secretary of State will consult vulnerable people, including people with a learning disability, to ensure that education and training provided by this body will create a workforce that meets this group’s needs. Consulting and listening carefully chimes with the Government’s intentions through their response to the Francis inquiry, which stated:
“We will listen most carefully to those whose voices are weakest and find it hardest to speak for themselves. We will care most carefully for the most vulnerable people—the very old and the very young, people with learning disabilities and people with severe mental illness”.
This is a most welcome commitment, as currently people with a learning disability are not receiving appropriate care. On Tuesday 21 May, the Parliamentary and Health Service Ombudsman published its report into the death of Tina Papalabropoulos. Tina was 23 and had a learning disability. She died on 30 January 2009 at Basildon hospital in Essex. The ombudsman found that the hospital did not give her the treatment she needed or even meet her basic care needs. Unfortunately, this is not an isolated incident, and there is substantial evidence that poor care exists across the health service.
Early this year, the confidential inquiry into the premature deaths of people with learning disabilities in the south-west reported on its study of the deaths of 233 adults and 14 children with a learning disability. It found that 42% of the deaths were premature and that 37% would have been avoidable if good quality healthcare had been provided. On a national level, this equates to over 1,200 adults and children with a learning disability across England whose deaths should have been avoidable with good quality healthcare. This comes as no surprise to many. The Department of Health highlighted the issue back in its Valuing People and Valuing People Now strategies, and the excellent report by Sir Jonathan Michael, Healthcare for All, set out a series of recommendations for improving care for people with a learning disability. It is these people whom the Secretary of State should consult when setting objectives and priorities for this most important of public bodies. Without the input of people with a learning disability and their families, we will fail to change a system and a culture that in many cases provide substandard care for the most vulnerable in our society.
I realise that the Minister will probably reply that in order to publish the objectives and priorities for the forthcoming year of Health Education England, the Secretary of State will have consulted the parties concerned. However, as an actor who, years ago, used to drop his trousers for a living, I nowadays prefer the security of belt and braces, and I hope that the Minister will be able to offer this.
Earl Howe
My Lords, I understand the point. In view of the hour, if I may, I will write to both noble Lords to flesh out the remarks that I have made. I hope that I can give them some comfort in that area.
Amendments 25 and 27, tabled by the noble Lord, Lord Hunt, focus on the importance of long-term and national approaches to workforce planning in education and training, as does Amendment 26. We have strengthened the Bill, following feedback in consultation and at pre-legislative scrutiny, in Clauses 87 and 93 to reflect the importance of HEE and the LETBs taking a long-term perspective on workforce planning and education and training. It is the Government’s expectation that all workforce planning, be it national level planning by HEE or local planning by the LETBs, should be based on a well informed, long-term workforce strategy that looks at needs over the next five years, 10 years or beyond. Any workforce strategy to be credible and deliverable has to be developed in partnership with those partners and stakeholders who have a stake in it. The very same principle applies to the development of national workforce priorities and outcomes and the Government are committed to working with everyone involved in education and training to shape the education outcomes framework and the mandate for Health Education England.
Health Education England will be expected to develop a national workforce plan, building on the local plans developed across England by local education and training boards. I hope that the noble Lord will feel reassured by those comments.
I turn now to Amendments 33 and 14, which seek to amend the Bill to require HEE to have regard to any official guidance and standards on staffing numbers and skill mix. HEE must work with commissioners and healthcare providers to ensure that workforce plans focus not only on how many staff are required but the breadth of skills required to deliver safe services. These plans need to be integrated with service and financial planning so that the needs of all patients and local communities can be met. Individual healthcare providers are best placed to determine how many staff they need to employ, the skill mix required across the various teams and how they need to deploy them to support services and so on. It is the responsibility of individual healthcare provider boards to be accountable for staffing levels and the skill mix of staff in their organisations. Where changes are planned to the size and shape of the workforce, including the skill mix, healthcare organisations must provide assurance that the safety and quality of patient care is maintained or improved. The process should include clinical involvement, leadership and sign off. I hope that these comments will be reassuring.
The noble Lord, Lord Hunt, asked me about the definition of “sufficient” and whether we were talking about equilibrium or oversupply. I will write to him on that, but in delivering that duty, HEE will seek to match supply and demand so far as that is practically possible. It will also promote the importance of a flexible workforce that can adapt to changing circumstances.
I will also, if I may, write on the issue of staffing ratios. I would just say here and now that staffing is clearly not just about crude numbers and not just about nurses. It is also about how the staff work and ensuring that the right staff are in place to meet the needs of the patients whom they are looking after. Again, it is local healthcare providers that are in the best place to decide how to configure those staff in the right way and to ensure better outcomes and value for money. It really depends on the skill mix, the clinical practice and local factors. I think we would say that it is right that nurse leaders should have the freedom to agree their own staff profiles. But I shall follow up that point.
Amendment 19 seeks to amend Clause 86(2) to add to Health Education England’s main functions the promotion of the importance of practical based training in the education of clinicians. I wholeheartedly agree that practical experience while training is essential to ensure that clinicians have the necessary skills to deliver high-quality and compassionate care and have the correct values and behaviours to practise in the NHS and public health system. It is the responsibility of the professional regulators to ensure that the right standards are in place for professional education and training. Practical experience is already a requirement of the professional regulators. Nursing students, for example, are required by the Nursing and Midwifery Council to undertake half of their training in a practice setting. The GMC also expects every medical student to gain practical experience of working with patients throughout their degree. We have placed a strong duty to secure continuous improvement in the quality of education and training on Health Education England. HEE is already working with the professional regulators, as I have already mentioned, to ensure that the Bill remains clear and simple. However, we have not specified the integral elements of the training programmes to which this duty applies. I would add, though, that the need for practical experience is one of the key priorities that the Government have set for the Health Education England Special Health Authority in the mandate. Health Education England will work with the LETBs and healthcare providers to deliver high-quality clinical and public health placements that provide students and trainees sufficient time working with patients to gain experience.
On Amendment 29, I can reassure the noble Lord that, where appropriate, Health Education England will take a national lead in the planning and management of education and training activities. The Bill already makes provision for this in Clause 94(2). The HEE Special Health Authority has already taken on responsibility at national level for crucially important arrangements to manage recruitment into foundation and specialty training programmes for junior doctors. Where there are controls on workforce numbers at national level—for example, in medicine or pharmacy—it will work with partners such as the Higher Education Funding Council for England to develop national plans that will deliver the staff needed across England.
Amendment 30 seeks to amend Clause 88 to add a requirement for Health Education England to have regard to the need,
“to co-ordinate its activities with the NHS in Scotland, Wales and Northern Ireland”.
Of course, it is very important that HEE works closely with the other UK nations in developing workforce plans and shaping education and training. It will be important for it to take a UK-wide perspective and, where appropriate, an EU-wide or indeed global perspective in planning for the future and reforming education and training. I refer the Committee to paragraph 17 of Schedule 5, which enables Health Education England to exercise corresponding functions on behalf of the devolved authorities. The special health authority is already working closely with its partners in Scotland, Wales and Northern Ireland, building on previous arrangements.
I sympathise completely with Amendment 28 and I wholeheartedly agree that there should be equality of funding for education and training across England. Moving to a tariff-based system for funding clinical education and training would enable a national approach to the funding of clinical placements and would provide a more level playing field between different providers. It will ensure that providers are reimbursed fairly for the education and training that they deliver and are incentivised to provide high-quality clinical placements to their students and trainees. For consistency of opportunities across the country, Clause 85 places a duty on HEE to ensure that sufficient numbers of health professionals are trained and available to work in the health service throughout England.
I hope that noble Lords will feel reassured by those remarks. Before I close, I will quickly respond to my noble friend Lord Willis, who expressed concern about the mandate containing little on nursing and support workers. There is a clear and strong commitment to supporting the development of the care assistant support workforce. Similarly, there are clear national priorities focusing on development of the nursing and midwifery workforce. Again, if I can elaborate on that in writing, I would be happy to do.
Lord Hunt of Kings Heath
My Lords, I am very grateful to the noble Earl for that comprehensive response. I am sure that we will all want to study it very carefully in Hansard. I will just make two points. One is that I hear what he says about the obvious intention of HEE to undertake long-term planning, but putting something in the Bill might help it with that. Secondly, I realise that my amendment on practical-based training is not very sophisticated but there is a kernel of truth within it that I would like to pursue on Report. But I am most grateful and beg leave to withdraw my Amendment 11.
NHS: GP Services
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Lord Hunt of Kings Heath
My Lords, first, I refer noble Lords to my health interests as set out in the register. The noble Earl is certainly right about one thing: that the health and social care system is under huge pressure. Hospitals are full to bursting, discharge is becoming ever more difficult, and social care and the voluntary sector are struggling to fulfil the demands being placed upon them. However, from the Statement made by the Secretary of State in the other place, it seems that the Government are seeking to blame everyone but themselves.
For instance, we have heard a lot about the GP contract, but can the noble Earl say why it has taken nine years for that contract to impact on A&E services? These are the very same GPs to whom, only a year ago, the noble Earl was saying we should hand over £80 billion for them to commission services without expertise, experience or inclination. Does he agree that the real causes of the crisis are the government-induced collapse of adult social care, the reduction in nurses, the closure of walk-in centres and ministerial pressure to introduce the NHS 111 service way too soon? Does he accept that all that has happened on the watch of the noble Earl and his ministerial colleagues?