Care Bill [HL]
Lord Hunt of Kings Heath Excerpts(12 years, 5 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.
Care Bill [HL]
Lord Hunt of Kings Heath Excerpts(12 years, 5 months ago)
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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.
Care Bill [HL]
Lord Hunt of Kings Heath Excerpts(12 years, 5 months ago)
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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?
Care Bill [HL]
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Lord Hunt of Kings Heath
My Lords, we are approaching the end of what has been a serious and expert debate on the Care Bill, which has clearly drawn considerable support from your Lordships’ House. However as speaker after speaker has pointed out, there is a marked contrast between the Bill’s intentions and the reality of the health and social care system, which is under huge financial pressure at the moment. Of course, this Bill puts new pressures and responsibilities on local authorities, but there are no signs yet as to how those authorities are to find resources.
We are happy to co-operate in postponing deliberation of Part 1 of the Bill, to allow it to take place after the spending review has been announced. However, in a sense that concerns the future and future responsibilities. The fact is the crisis is here now in relation to social care. Very little has been heard from the Government about how they intend to respond to it. I hope the noble Earl will say something about it tonight. Many noble Lords have referred to the eligibility criteria and the intention to set this at a national level to get consistency and deal with the issue of the huge variation that is now apparent throughout the country. This has been widely welcomed, but I would tell the noble Earl that we certainly expect the Government to publish the all-important draft regulations before we go into Committee to deal with this important matter. I would be grateful if the Minister will confirm that he intends to do that.
He will know that there is widespread expectation that the Government will set the national level at the “substantial” level. I do not expect the noble Earl to confirm that tonight, but does he agree with the noble Lord, Lord Rix, that local authorities have increasingly moved the threshold up to the substantial level, with, of course, prevention and early intervention being unavailable? May I also ask him about the risk of those local authorities which do not at the moment set the threshold at the substantial level, actually raising it in the light of the national criteria being set at that level? That way, we will have national consistency, but it will be consistency where provision is at the meanest. That would cause considerable concern in many local authority areas.
The noble and learned Lord, Lord Mackay, and my noble friend Lord Warner raised the question of Clause 22 and the all-important boundary definition between the means-tested social care and the free-at-the-point-of-use NHS. The noble Lord, Lord Sutherland, hopes that at some point this might be a thing of the past, but at the moment this is a critical delineation between the two services. The Minister will know that the Select Committee was concerned that a court might view any changes in the wording as implying a change in the meaning of the provision. It is important that we hear a response from the Government about why we ought not to worry about that.
The noble Baroness, Lady Campbell, spoke so eloquently of the problems of people being shunted between the two services because of the cost implication between local authorities and the NHS. At the same time, the noble Baroness passionately promoted the need to support disabled people to be as independent as possible. This is not an issue that will go away and we will need to come back to that in Committee in terms of the new meaning—if it is a new meaning— in Clause 22.
This is not just a Bill for older people, but the challenges that older people face are formidable, as my noble friend Lady Bakewell said. Like my noble friend Lord Lipsey, I welcome the Dilnot provisions and the cap—as far as they go. However that is not the complete picture. The cap and increased threshold will reduce the risk of catastrophic costs, but there is a concern about the way that people of modest means will be treated. I listened with great interest to what my noble friend Lord Lipsey said about the operation of the means-tested tariff and the impact on people with modest income. My noble friend Lord Warner does not quite take his view on that, but it would be good to have a debate on this in Committee.
I would also be interested to know whether my noble friend Lord Lipsey has taken into account that in some benefits the first £6,000, and in others the first £14,000, are exempt from the tariff, which in itself is progressive, with those with the most savings hardest hit. It is important we come back to that.
My final point on Dilnot is about the insurance market, which a number of noble Lords raised. What is the noble Earl’s current assessment of the prospects of an insurance market developing? Has his department been in recent communication with the ABI and can he say any more about the confidence that he has in insurance products developing? This is very important in reaching a conclusion about the likely success of the Dilnot proposals in this legislation.
Finally in this area, I turn to a point raised by my noble friends Lord Lipsey and Lord Warner. The actual administration and assessment that will have to take place, particularly as thousands of self funders will need to be assessed under these proposals, will lead local government into a major administrative task and to an increase in disputes and legal challenges. The Joint Committee was not confident that Ministers had fully thought out the implications for local authorities of these changes. Will the noble Earl comment on that and also on my noble friend Lord Warner's suggestion that we need to establish tribunals in order to deal with disputes to keep them out of the courts as far as possible?
Very good points were made about the need for impartial information in relation to Clause 4. When one thinks about some of the financial consequences of the decisions made, it is a powerful argument. I also hope that the noble Earl will respond to my noble friend Lord Patel in relation to Clause 68 and the question of aftercare and the implications that it has in relation to Section 117 of the Mental Health Act 1983. We had extensive debates on these matters only a few months ago. I hope that this is not opening up the question and is not a reinterpretation.
On carers, my noble friend Lady Pitkeathley spoke eloquently about the importance of these provisions, and we welcome them. But there is a question about why they do not relate either to parents caring for disabled children or young carers. As Barnardo’s has said, young carers represent a uniquely valuable group of people whom the Government should be ensuring receive help to address the very serious effects that caring has on their lives. The noble and learned Lord, Lord Mackay, made an important point about the need to ensure that, in the case of children caring for adults, the impact on the child must be given due consideration.
My noble friend Lady Wilkins talked about housing. The point she raised is surely right. What concerns me is the lack of very much reference to housing provision or housing authorities in the Bill. I am sure that we can look forward to some amendments in that direction from my noble friend.
On safeguarding, it is a matter of regret that there is no duty on providers to report to local authorities where they suspect the risk of abuse. It is also a matter of regret that there is no clause allowing for power of entry. This was raised by the Joint Committee and it was clear that there should be a power of entry for local authority representatives where a third party is refusing access to a person who may be at risk of abuse. I know that the Government will say that the consultation produced a lot of people opposed to that. But if we are to take abuse seriously, we should come back to examine whether a power of entry is necessary and should be required.
On Part 2, there is the NHS failure regime. I was pleased that the noble Earl’s officials gave us a briefing on this. It is rather complex and there seems to be a risk of confusion of roles between the two regulators, CQC and Monitor. Will he respond to the question raised by my noble friend Lord Warner about non-foundation trusts? I should have declared an interest as chair of an NHS foundation trust and indeed as a consultant and trainer with Cumberlege Connections. Why are the weaker organisations subject to a much less regulated framework than the foundation trusts? Why are the non-foundation trusts not covered in the Bill?
I am disappointed that there is only a partial implementation of the Francis recommendations, particularly as far as primary legislation is concerned. For instance, where is the duty of candour? We have the offence in Clause 81 of publishing false or misleading information. But Francis wanted a statutory duty of candour on healthcare providers to inform patients or appropriate persons if treatment has caused death or serious injury to the patient. Why is that not in the Bill? Where is the registration of healthcare support workers, as the noble Baroness, Lady Emerton, suggested?
On public health, I agree with noble Lords who regret that there is no provision for standardised packaging for cigarettes. I look forward to a continuing debate on that matter. On Health Education England, some very important points were raised by noble Lords. I would particularly refer to my noble friend Lord Turnberg’s comments about the LETBs and the need to ensure high quality in training and the involvement of postgraduate deans. As regards research, again, the provisions are very welcome but there is real concern that this country is losing out in terms of the number of multi-centre trials that take place here. Does the noble Earl thinks that the HRA should be given more authority over both the local research ethics committees and NHS trusts in terms of R&D approval? We cannot just leave it to these different bodies when the whole prosperity of our country is in many ways based on this kind of investment.
This has been an excellent debate. We look forward to the responses from the noble Earl. He will know that there are a lot of provisions here that command general support but, ultimately, the real concerns relate to current and future resources, and to the need for the Government to respond strongly in convincing argument about the kind of integrated services that are required to ensure that the provisions of this Bill will be implemented. The Government need to show that they really do get it and are going to come forward with those proposals.
NHS: GP Dispensing
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Earl Howe
My Lords, the rules as they stand do not present a major obstacle for disabled patients. Many pharmacies, for example, offer a free prescription collection and delivery service if a patient encounters difficulty in getting into the pharmacy premises. Under that arrangement, the pharmacy collects the prescription from the surgery on behalf of the patient, dispenses it and delivers it to the patient. Patients can contact their local pharmacies to see whether they offer that service.
Lord Hunt of Kings Heath
My Lords, I refer noble Lords to my health interests in the register. I well understand why the noble Earl does not want to reopen the issue, having chaired meetings at the department of the two representative bodies myself. However, I wonder whether the current arrangements are justifiable in 2013. Does the Minister not think that it might warrant his department asking an independent reviewer to look at the situation again, particularly from the point of view of the consumer and patient rather than of either the pharmacist or the dispensing doctors?
Earl Howe
I am sure that the noble Lord is as aware as anyone of the balance that has to be struck here. A GP’s primary purpose is to provide comprehensive medical care and treatment to his or her patients. More than 90% of prescription items are dispensed by pharmacies, which is what most patients expect. However, we must have arrangements to enable patients who live in rural and more remote areas to access medicines more easily. I think the noble Lord will understand that the arrangement for some GPs to provide dispensing services has always been the exception rather than the rule. I do not think there is an appetite on anyone’s part among the professions to reopen these arrangements.
Emergency Services: Paramedics
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Earl Howe
My Lords, it is up to the employer—in this case, the ambulance trust—to ensure that it has a body of suitably trained and experienced staff. That depends on regular monitoring and ensuring that training is kept up to date. Equally, it is up to commissioners to ensure that the service that they are receiving is delivered by suitably experienced and qualified people. The CQC will also have a role in this regard.
Lord Hunt of Kings Heath
My Lords, I refer noble Lords to my health interests in the register. To follow on from the noble Earl’s final comment, is this not an example of staff such as nurses being trained to be practitioners in the health service but finding that they have not been given enough practical training when they come to treat people on the front line? The noble Earl will know that Health Education England is being established as a non-departmental public body in the Care Bill. Can we ensure that that body has much more control over the curriculum of those being trained to fill these very important posts?
Earl Howe
The noble Lord makes a series of very important points about training. The answer to his final question is that, yes, Health Education England will certainly be looking at the degree of training required to fulfil specific professional tasks across the piece in the health service, including the ambulance service. However, I do not think that this case reflects a lack of appropriate training on the part of the individuals involved. They were appropriately trained; they were just incompetent. That is the point.
NHS: 111 Telephone Service
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Lord Hunt of Kings Heath
To ask Her Majesty’s Government what steps they are taking to improve the implementation of the NHS 111 service.
Lord Hunt of Kings Heath
My Lords, I beg leave to ask the Question standing in my name on the Order Paper and refer noble Lords to my health interests in the register.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we recognise that the NHS 111 launches in March did not go as smoothly as planned and that a number of providers have delivered an unacceptable service, especially at weekends. NHS England is working closely with clinical commissioning groups to stabilise providers who have failed to deliver an effective service and to ensure that areas yet to go live are in a safe and fit state to do so.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl for that response, but on what grounds was the decision made to go ahead with the national rollout in the light of the results from the pilots, which showed problems with the scheme, and the fact that many people in the NHS advised Ministers and NHS England not to roll it out because it was not ready?
Earl Howe
My Lords, the University of Sheffield did work for the department reporting on the first four NHS 111 pilots. That showed that 92% of patients were satisfied with the service and that 93% felt that the advice given was helpful. It also found that, overall, the service was meeting its objective of getting people to the right place first time. On that basis, it was considered safe to go ahead with a rollout. Unfortunately, in particular areas of the country, the resources deployed to meet the demand have not been accurately assessed, but I stress that that is in a minority of locations.