Health: Neurological Services

Lord MacKenzie of Culkein Excerpts

Tuesday 20th November 2012 Lords Chamber

[Lord MacKenzie of Culkein]

My Lords, I join in the thanks to my noble friend Lady Ford for securing this important debate on neurological services. I have spoken in a number of debates on this subject over the past five or six years. I have an interest, partly as a nurse but more specifically because a few years ago a very close friend and colleague of mine died from motor neurone disease. After diagnosis he had good support from the health and social care professionals as well as brilliant support from St Raphael’s Hospice in the London Borough of Sutton. It was a very different story for another colleague of mine, whose father’s care before his death was nothing short of scandalous, with health and social services unable to get their act together, either within each service or between the two services. Those are two stories in different parts of the country—the postcode lottery—so I hope that I can be forgiven for concentrating, like the noble Baroness, Lady Masham of Ilton, on motor neurone disease.

I pay tribute to the Motor Neurone Disease Association for its untiring support for those living with motor neurone disease and for its funding of cutting-edge research into this miserable, rapidly progressing and ultimately fatal disease. I suspect that it is going to be a long time before we have a world free of motor neurone disease and, until that time, we need to concentrate on the best possible care for those living with it. It is to be welcomed that the Government have added improving the experience of care for people at the end of their lives to the new mandate issued to the NHS Commissioning Board in the past few days. That is good so far as it goes. It is perhaps not surprising that there is no specific reference to motor neurone disease in the mandate, but I was confident that there would be some reference to neurology. If there is one, I am afraid that I have missed it.

I find that omission to be surprising to say the least, given that, as has been said, there are something like 8 million people with neurological conditions in this country and about 500,000 new diagnoses each year. According to the Neurological Alliance, the cost to the National Health Service is some £4.3 billion each year, with social care budgets adding another £2.4 billion. That is a lot of money, but it is not surprising when almost 20% of hospital admissions are for neurological issues. Emergency admissions under this heading in the five years up to 2009-10 increased by 32% compared with 17% for the National Health Service as a whole. That does not sound to me as if there has been progress.

A great many conditions are wrapped up under the heading “neurological conditions” and these in turn get wrapped up, it seems, in the generic description “long-term conditions”. Motor neurone disease is not a long-term condition. The average lifespan after diagnosis is 14 months. So what needs to be done? It would be good if the Government were to revisit the reports of the National Audit Office of December 2011 and the Public Accounts Committee of March 2012. It is particularly disappointing that the Government have rejected the advice of the PAC relating to the appointment of a national clinical lead for neurology. Quite frankly, it is difficult to understand. Neither have the Government accepted the advice to mandate the commissioning of neurological illnesses. We know that national clinical leadership works. It has done a great job in, among other things, driving improvements on strokes and cancers. It is now essential that this is done for neurological conditions, so that improvements are driven there as well and can lead to a far greater visibility for neurology.

If there is a lack of visibility for neurology generally, specific conditions such as motor neurone disease are hardly on the horizon. Most general practitioners will see one case, perhaps two cases, if that, in a whole career, but five persons die from motor neurone disease every day and there are probably 5,000 living with motor neurone disease at any one time in the United Kingdom. It is notoriously difficult to diagnose—it can be done only by excluding every other possibility—and rapidly progresses, to the extent that 18 health or social care professionals can be providing care at any one time. Anyone with any appreciation of motor neurone disease must know that it cannot be dealt with by a one-size-fits-all approach to long-term conditions.

It is good that the National Institute for Health and Clinical Excellence has been asked to develop clinical guidance and a quality standard for the rarer neurological diseases, but is that likely to be forthcoming in the near future, or is it at the tail end of the very long list of quality standards that NICE has been asked to develop? Perhaps the Minister can tell us about that.

Any delay, together with the absence of a national clinical lead, certainly gives me no confidence in the effective commissioning in the new National Health Service of the complex services necessary for motor neurone disease so that we can get away once and for all from the fragmentation, lack of co-ordination and postcode lottery. The present situation is not good enough; indeed, it is unacceptable in 21st-century health and social services. It is self-evident that there is an urgent need for NICE to expedite its guidance and quality standards for motor neurone disease.

These poor, fragmented care pathways, including emergency admissions to hospital, together with the lack of access to palliative and respite care services, can double or triple the costs per patient per year from the estimated £200,000 that good care costs. There is a clear imperative to get this right. It is a classic case where what is best for the patient is also good for the taxpayer.

In summary, can we have as a matter of urgency a national clinical lead for neurology, the mandating of the commissioning of neurological conditions and, I stress again, the expediting by NICE of clinical guidance and quality standards for the rarer neurological conditions? I very much look forward to hearing what the noble Baroness will tell us about the way forward and again thank my noble friend Lady Ford for giving us this opportunity to discuss this important matter.

Health and Social Care Bill

Lord MacKenzie of Culkein Excerpts

Monday 19th December 2011 Lords Chamber

[Lord Patel]

My Lords, I shall speak to Amendments 338 and 340, to which I have added my name in support of the noble Baroness, Lady Emerton. For those of your Lordships not familiar with the amendments, they are to do with the regulation of healthcare support workers. As many noble Lords will know, these workers were introduced into the health service just over a decade ago, and they are untrained, unqualified and unregulated. There are 300,000-plus of them in the health service, with many more working in nursing homes.

Any debate about the regulation of healthcare support workers will need to take account of current workforce trends. In April 2011, the Royal College of Nursing reported that NHS trusts were increasingly looking to reassess nursing roles in order to deliver short-term reductions in the wage bill without a full clinical assessment of the impact of this action on patients’ safety and the quality of patient care. The RCN reported a notable change in the skill mix of teams, with an increased reliance on unregulated healthcare support workers.

The other workforce in nursing is trained and regulated. It is made up of registered general nurses and registered midwives, and we also used to have state-enrolled nurses. The view could be taken that it is the responsibility of employers to make sure that their workforce is adequately trained and has the skills to deliver the care, but many recent reports with which noble Lords are familiar highlight poor-quality nursing care. Some of them have appeared in the press and include the failings at Stafford Hospital, where hundreds died unnecessarily, and at Winterbourne View care home, where staff were filmed abusing vulnerable patients, as well as a series of critical reports, most recently from the Care Quality Commission, which has condemned NHS care for the elderly. Some, including regulatory authorities and particularly the Council for Healthcare Regulatory Excellence, favour the employer-led model of training of healthcare support workers or of those who are not trained yet provide nursing care. This model was introduced in Scotland. The important thing is that it has never been evaluated. That needs to be done first. Secondly, and more importantly, the ratio of trained nurses to untrained support workers is quite different in Scotland. Anyone who promotes this model needs to look at that first.

I return to some of the issues. The noble Baroness, Lady Emerton, made all the points in an excellent introductory speech. It is a pity that we did not have a continuation of the debate so that we could have heard her comments and responded to them. However, the Bill proposes that the regulators of healthcare professionals should have the ability to establish voluntary registers for currently unregulated workers and professionals who are, or have been, engaged in work that supports or otherwise relates to work engaged in by members of the profession that the body regulates.

In proposing voluntary registration, the Government have accepted that unregulated workers supporting healthcare professionals represent a risk to public protection that needs to be addressed. If they did not, why would they even consider voluntary registration? It must be because they think it is a risk. Voluntary registration for healthcare support workers carrying out tasks delegated by nurses or midwives is not sufficient to protect the public.

The other argument used is that it is the trained nurses—the registered nurses—who supervise these support workers who are not trained or regulated. How can a nurse, or two nurses, in a ward of 15 or 16 intensive care patients, supervise three or four unregulated, untrained workers, who then carry out nursing tasks? The noble Baroness, Lady Emerton, cited a real case of such a worker measuring blood pressure who did not understand why she was doing it. If one is going to have people who look after ill, frail people, one needs to make sure that they are trained properly, that their training is assessed, and that they are regulated. I understand that this cannot be done overnight, particularly as we now have nearly 400,000 such people working in the health service, but there ought to be some mission to do this in a relatively short time, maybe even in two or three years. To go after voluntary registration is not the answer.

There is currently no consistent UK-wide training standard for healthcare support workers. Courses can range from an hour-long induction up to NVQ level 3. Assistant practitioners are experienced health support workers. They are different, and they may receive training up to NHS-level band 4, which is equivalent to the level of the previous state-enrolled nurses, but, again, there is no consistency across the UK. Clause 231 gives no indication that a voluntary system will be underpinned by consistent UK-wide standards of training that will assure the public that employers who employ health support workers have the knowledge and skills that they need to practise safely. I strongly support this amendment. Whenever the noble Baroness wishes to call a vote, I will join her.

[Lord MacKenzie of Culkein]

My Lords, I have long been an advocate in the cause of statutory regulation and registration of healthcare support workers. When one has been around the health service for a long time, it is not unusual to see the wheels turn full circle. We went from support staff to auxiliary nurses, to nursing assistants, to state-enrolled assistant nurses. Then the word “assistant” was dropped and we had state-enrolled nurses. Then, as the noble Baroness, Lady Emerton, said earlier, the roles of the state-enrolled nurse and the registered nurse became very confused and the titles became interchangeable, which should never have happened. Then we moved to Project 2000 and the move from hospital-based training to higher education, and we are now moving from diploma to an all-degree profession, which is right and proper.

In 1999, my union, the Confederation of Health Service Employees, supported Project 2000, but we foresaw a gap that would be left by the ending of enrolled nurse training, which would lead to there being many more auxiliaries or healthcare assistants, as they became. We called for support workers to have about a year’s training to an agreed national standard and statutory regulation by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, as the regulatory body was called. We did not get that. The idea was opposed because it was argued that it would replicate the then existing confusion between enrolled nurses and registered nurses.

Where are we now? We have an explosion in the number of support staff who have taken the place of enrolled nurses; there are far more than any of us ever envisaged at the time. As the noble Lord, Lord Patel, said, more than 300,000 support workers are now employed in various roles with a number of job titles. One figure that I saw in research produced by UNISON said that there were more than 120 different job titles for healthcare support workers, which is astonishing.

We have a situation in which the patients do not know who is caring for them. It is not just a question of uniform, although that is important. Support staff carry out many duties that were previously the role of regulated nurses. Many of those roles, such as nasal gastric tubes, cannulation, catheterisation and blood pressure, are intimate and invasive, as we have heard. Almost uncannily, in view of what the noble Baroness, Lady Emerton, spoke about, I spent some time in hospital a couple of years ago when I had my blood pressure taken sitting in a chair beside the bed and my diastolic pressure was down to 40. I said to the healthcare assistant who took that blood pressure, “I had better get back to bed and I think you’d better call a senior nurse and doctor”. She said, “No, you are going down for an MRCP scan; just sit where you are”. Fortunately, being a nurse, I knew what I was talking about and I was able to get a doctor and a nurse, and before very long I had massive amounts of fluid pumped into my veins to restore my blood pressure. Had I not understood the situation, that could have resulted in a serious condition. It is quite frightening. You can be trained to take blood pressure, but not trained in the skills of observation and in understanding the readings that are being taken.

With the drive to reduce costs, there is, and will be, more substitution of registered nurses by healthcare workers. In effect we have a new second level, but that new second level is not regulated and not registered and the staff are not professionally accountable for their practice. That is not good enough. That is not in the interests of patients’ safety or protection. Nor will assured voluntary registration deal with the matter. Voluntary registers already exist for other professions and there are very real concerns about their inadequacies. They have no teeth, and staff can leave a voluntary register, particularly if there is any investigation for possible discipline.

The registration and regulation of healthcare support workers is supported by the Nursing and Midwifery Council, by the Royal College of Nursing, and by UNISON, although in fairness I should say that UNISON would prefer registration by the Health Professions Council. Registration is supported by the Queen’s Nursing Institute, by the health committee in another place and, most importantly, by healthcare assistants themselves.

In the Nursing Times of 6 December, I was interested to see in a small article about the Mid Staffordshire NHS Foundation Trust public inquiry that Robert Francis QC spoke of 20 issues that he would consider when drawing up his recommendations, which are due to be published next year, and the regulation and training of healthcare assistants was to be first on the list. I hope that that does not mean that they will carry the can for all the problems in Mid Staffordshire because that is certainly not the case; they go to a much higher level than that. Counsel to the inquiry, Tom Kark QC, said that the lack of regulation of healthcare assistants appeared to be surprising and dangerous.

There is inexorable pressure for this matter to be dealt with—and dealt with soon. It is not something that can be put on the long finger. If there is a strong recommendation from the Mid Staffordshire inquiry, we cannot leave it to be dealt with in a future Bill because we will not be getting another health service Bill for some time. This Bill gives us the opportunity to do this and to get it right. I strongly support the amendment by the noble Baroness, Lady Emerton. Healthcare assistants who have work delegated to them by nurses should be properly regulated and registered.

--- Later in debate ---

[Baroness Northover]

I have seen many, many changeovers. The proposal is being brought forward so that registered, regulated nurses have a better idea of when and how to delegate, and that is extremely important for the reasons that the noble Lord has just indicated. As I have indicated, the training and national standards of healthcare workers, to which the noble Lord, Lord Patel, referred, are also important—as is taking that forward so that the registered nurses are aware of the kind of training that those healthcare workers have had. I want to pick up on the case that the noble Baroness, Lady Emerton, mentioned about the healthcare worker who was taking a patient’s blood pressure but did not know what the reading meant. Surely, it was for the person to whom that was reported to take action on the significance of that. That information was to be passed on to somebody else to read, understand and interpret.

[Lord MacKenzie of Culkein]

But if that healthcare assistant does not have the basic training or an understanding of the reading that she or he has just taken, they may not see the importance of reporting it to another nurse.

[Baroness Northover]

I am not suggesting that they would. What I am suggesting is that the registered nurse might go and check the chart.

--- Later in debate ---

[Lord MacKenzie of Culkein]

My Lords, I support this group of amendments. I want to make just a couple of points, as I think that most of the others have already been covered.

I am looking at some information sent in an open letter from the Registration Council for Clinical Physiologists to Anne Milton, the Parliamentary Under-Secretary of State in another place. Interestingly, in that open letter the registration council, which operates a voluntary register, takes the view that the council is rather toothless. It says that the professions covered by clinical physiologists will continue to be,

“saddled with a toothless system of voluntary registration, in which those managing the registers are exposed to unacceptable legal risk when attempting to enforce the meagre sanctions at their disposal and maintain professional standards”.

It says it is evident that those administering the current inadequate voluntary registration process are being threatened with civil action by those whom they are forced to reprimand. It is a pretty poor state of affairs when those who are trying to enforce professional standards are themselves threatened with legal action.

I know from talking to people involved with the registration council that people leave the register when disciplinary issues come to the fore. I gather that in one instance a person left the register when faced with discipline, emigrated to Australia, continued to practise and got in trouble there. As I understand it, the Australian statutory body that exists for clinical physiologists was astonished to discover that there was no statutory regulation in force in this country.

I do not think that we can continue with this so-called voluntary system and light touch. We need to do what other countries do and have statutory responsibilities and statutory training and registration for these very important groups of staff.

[Baroness Northover]

My Lords, these amendments seek to extend compulsory statutory regulation to physicians’ assistants in anaesthesia and clinical physiologists and to make changes to legislation to further provide for the compulsory statutory regulation of clinical physiologists.

I make it clear at the start that healthcare scientists such as clinical physiologists play an important and highly valued role as part of clinical teams, and this is also true of physicians’ assistants. It is a testament to their professionalism that the Department of Health is not aware of any general concerns about the standards of practice of either group. Furthermore, we need to be absolutely clear that the purpose of regulation is to protect the public, not to support the development of a profession.

Given the wider systems of assurance in place such as the Care Quality Commission’s registration requirements, and the vetting and barring scheme, the Government do not consider that the case for compulsory statutory regulation of these groups of healthcare scientists not already subject to regulation, and physicians’ assistants, has been made. However, we agree that there need to be processes to ensure high standards of care, and assured voluntary registration overseen by the Professional Standards Authority for Health and Social Care has the potential to provide this. It will ensure that there are robust standards of conduct and training. It will be open to employers and commissioners to insist on only recruiting staff on voluntary registers. Those doing so would secure many of the benefits of compulsory regulation. Both healthcare scientists and physicians’ assistants already have established voluntary registers and would be well placed to seek accreditation from the authority.

The noble Baroness, Lady Thornton, asked why we were not taking forward the regulation of clinical physiologists as recommended by the Health Professions Council. The recommendations of the Health Professions Council were not based on an assessment of the risk presented by a profession, but rather on whether that profession had already developed processes of assurance which prepared them for professional regulation. There is therefore no evidence that compulsory statutory regulation is necessary to mitigate the risks posed by the professions recommended for such regulation by the Health Professions Council. This is probably why the previous Government did not decide to regulate, although this is an issue that has been flagged up for a number of years. The professions recommended by the Health Professions Council for compulsory statutory regulation will be well placed to join the system of assured voluntary registration that we are proposing.

The noble Baroness, Lady Thornton, asked about research in terms of regulating clinical physiologists. We are not planning on commissioning research into the case for regulating them, but we will review the case for introducing compulsory statutory regulation for clinical physiologists and, obviously, others in the light of experience of assured voluntary registration, and the evidence about risks available.

Health and Social Care Bill

Lord MacKenzie of Culkein Excerpts

Wednesday 16th November 2011 Lords Chamber

[Baroness Masham of Ilton]

My Lords, providing services for the prevention and treatment of harmful drinking and alcohol dependence is essential. Alcoholism ruins many lives. There is a very worrying rise in liver disease, especially among young women, caused by a combination of hepatitis C, which we have discussed today, and dangerous levels of drinking. It is causing great pressure on hospitals’ liver disease wards.

Those in young offender institutions and prisons have often been involved in domestic violence, drink-driving, fights and violent crime due to too much alcohol. For years, prisons have had money for drug-abuse rehabilitation, but very little for alcohol misuse, although the problem has been bigger. As a result of the problems alcohol contributes to crime, I hope that the Government will try to promote alcohol-misuse rehabilitation in prisons. It should not be left out.

Huge pressure is put on the staff of A&E departments, especially on Friday and Saturday nights, by alcohol abuse. One young doctor who works in an A&E department here in London told me the other day that he was concerned that it took so much longer to attend to patients who were drunk that he felt that some other patients were being put at risk. Alcohol abuse can cause all sorts of problems. It should have concerted effort spent on it. Many voluntary organisations help with alcohol-abuse rehabilitation, but the private centres are very expensive and are not available to most people. There is also the problem of coaddiction to drugs and alcohol which has affected many young lives.

[Lord MacKenzie of Culkein]

I have put my name to Amendment 202 which deals with general practitioners. I do not intend to detain the Committee because the points I was going to make have already been eloquently made by the noble Baroness, Lady Finlay of Llandaff, and others. I want to reiterate the point about general practitioners not identifying alcohol misuse. For the life of me, I cannot understand why there is no quality assessment framework indicator for screening for alcohol and why that is not part of the programme. There is evidence that screening works, as the noble Lord, Lord Brooke of Alverthorpe, said. It is clinically cost-effective. There is an urgent need to prioritise the issue of alcohol abuse, and this amendment gives us that opportunity. I hope that the Minister will be able to say something positive about that this evening.

[Lord Northbourne]

I rise to support the amendment moved by the noble Baroness, Lady Finlay. One thing that has so far not been mentioned is that it is important to think about the alternatives to alcohol and to regular alcohol use. I used to spend a certain amount of time with very disadvantaged young people, and a great deal of their problem was boredom, inferiority complexes and no belief that there was any real future for them, so let us also think about all sorts of other things that they might be doing.