Covid-19: Vaccination Prioritisation

Lord MacKenzie of Culkein Excerpts

Wednesday 25th November 2020 Lords Chamber

[Lord Bethell (Con)]

I reassure the noble Baroness that no final decisions have been made; this is only interim advice. I point out in particular that the behaviours of individual vaccines might be quite different for different groups of people. It is only when we have the final phase 3 data on the vaccines that we will be able to make the decisions that she alludes to. We are considering the extremely vulnerable carefully. As I mentioned, a review is under way to see whether clinical factors should play a greater role in prioritisation.

[Lord MacKenzie of Culkein (Lab) [V]]

My Lords, I could not agree more with the noble Baroness, Lady Campbell. Motor neurone disease is an example of a fatal illness with a very short life expectancy after diagnosis. The Minister might well have seen recent publicity about the case of a six year-old child being unable to attend school in case he brings the Covid-19 virus home to his dad, who is living with motor neurone disease. I hope the Minister will agree that no family should be in the position of having to choose between their child attending school and the risk of shortening the already short lifespan of his father. Will he further agree that people living with motor neurone disease, as well as those with many other life-limiting illnesses, must be on the priority list for very early vaccination?

NHS: Staff

Lord MacKenzie of Culkein Excerpts

Thursday 30th November 2017 Lords Chamber

[Lord MacKenzie of Culkein (Lab)]

My Lords, I too am delighted that my noble friend Lord Clark of Windermere has secured this very timely debate. I agree with every single word, I think, that he said. Given my own nursing background, I will perhaps single out from among the other speakers the powerful speech by the noble Baroness, Lady Emerton. She touched on a lot of extremely important matters, and the news that she may shortly be retiring from this place will leave the House much worse off when it comes to dealing with very important health matters, particularly nursing.

There are lots of warm words about nursing and lots of compliments for the work of nurses, midwives and health visitors, and this is something that Ministers are only too happy to join in with. We had it from the Chancellor in his Budget speech in the last few days, when he said:

“Our nation’s nurses provide invaluable support to us all in our time of greatest need and deserve our deepest gratitude for their tireless efforts”.—[Official Report, Commons, 22/11/17; col. 1054.]


Nobody could argue with these words, but nurses and other health staff were expecting something more when it came to the rest of the Budget speech. The scrapping of the pay cap was announced, I think, last October. The widely expected nod in the Budget to a decent, unconditional, fully funded pay rise did not materialise. Instead, any increase above a miserable l% seems to be conditional on changes to the Agenda for Change pay structure.

I agree that there may be some aspects of that structure that might need to be looked at, tweaked or updated, but the real suspicion is of course that the Government want to reduce or remove payments for unsocial hours, and that they may want to deal with issues about so-called automatic increments and put new bars to progression on the incremental scales. We have already heard about issues of productivity, and I agree with the noble Lord, Lord Warner, that any negotiations with the staff unions that propose taking some of these conditions of service away are going to be extremely difficult.

I also do not know, and would like to know from the Minister, what is meant by productivity. How do you measure a nurse sitting down and talking with a patient? Are they supposed to be on the move every minute of every hour? Nurses, midwives, health visitors and most other health staff are working at full pitch, and I do not really know what is meant by productivity increases. I hope that the Government and the Secretary of State are not setting up the staff side for blame if they fail to reach agreement on some of these proposed robbing Peter to pay Pauline suggestions that may be coming forward. I can hear it now: “You would have got a bigger increase, but the wicked staff side failed to reach agreement with us”.

I have been around the health service and health service trade unionism for all of my working life until I came into this place. There have been many ups and downs and issues in nursing morale over the years. We have had good times, better times and a lot of bad times, but I am not alone in saying that it is worse now than I can ever recall. Pay and grading is of course one of the issues that affect nurse morale—how could it not be when pay is something like 14% lower in real terms than it was in 2010? It is an important reason why nurses leave the profession. Nurses cannot pay their bills, and in some cases need to go to food banks.

However, as soon as we ask a Parliamentary Question about nursing shortages, pressures or pay, what do we get? With the greatest of respect to the Minister, what we get are the formulaic, boiler-plate Answers telling us that we have X more nurses than we had in 2010 and have created Y more training places, and that pay is for the independent NHS Pay Review Body. The review body used to work reasonably well and held the ring between the Government—the Department of Health—and the staff side fairly well before it was effectively captured by the Government’s freeze and then the 1% pay cap.

We need to unpack these ministerial Answers. There may be more nurses now than there were in 2010, but that takes no account of the growing demographic change in the population. There are more elderly people than ever before, and that means more co-morbidities. There have been huge advances in medicine and surgery. We have fewer acute beds in this country than most OECD countries. For example, Germany has over six per 1,000 population, while we have less than 2.5. Perhaps that is why ambulances are queuing for far too long outside A&E departments, patients are not seen within target times, patients are on trolleys in corridors and, as we have heard in this debate, patients are sometimes discharged inappropriately early or in the middle of the night, without adequate provision at home, so that room can be made for the more acutely ill patients waiting in A&E.

It is not therefore surprising that there are huge pressures on nurses and other staff when on duty. There are 40,000 vacancies for nursing staff in England alone, and that takes no account of increasing shortfalls in the other UK countries. It is therefore not surprising that some research tells us we have the highest nursing workload and consequent burnout in Europe. That does nothing for staff morale either.

Then there is the hopeless funding of social care. How much did we hear about social care in the Budget? “Hopeless” seems to me to be the operative word because, without significant investment in social care, the future looks grim. That in turn adds to the pressures on the health service.

Ministers are fond of referencing 2010. In 2010, we had over 8,000 nurses working in social care, but there are fewer than half that number today, while nursing homes are having to close or reregister as care homes. The continuing lack of investment in social care is going to put even more pressure on the hard-pressed NHS, despite the additional funding that, while welcome, will be nowhere near enough to avoid the continuing pressures and problems. Some 40% of the funding needed is all that was offered—better than nothing but not good enough, as the funding asked for by Simon Stevens would only have returned us to the level of increases that we had in the first 60 or so years of the NHS.

A more recent but very important matter affecting the retention of nursing staff is the dramatic reduction in the funding for continuing professional development. We have already heard the figures: the budget, which was £205 million, has been chopped down to £83 million. Part of continuing professional development is the requirement that all nurses revalidate their registration every three years, but by far the largest part of the funding is needed to develop nurses and nursing as well as to bring in new roles. Why put the brakes on preceptorship for newly qualified nurses as well as the career development that is so important? Employers cannot now develop programmes for A&E, for operating theatres, for district nursing or for advanced practice in anything like the numbers that are needed because of the huge disinvestment in CPD. I understand that the Government did not reduce CPD for doctors, so why did they do it for nurses? Can the Minister explain the disparity between the ways in which the two professions have been treated? These are but some of the reasons why members of the nursing profession are unhappy.

I turn to the matter of joining the profession in the first place, where again we have had a huge disinvestment, this time by replacing the bursary scheme with student loans. We have heard much about how this plan is going to increase the number of university places available by not having a capped commissioning system; we are told that it would give students much more money. We heard some of that from the noble Lord on the Front Bench yesterday. Universities were up for it, at least initially, because they are in a marketplace and the prospect of more students brings in more money. Perhaps the most important reason is the fact that the Treasury hopes that, by introducing the wheeze of ending bursaries, it will save £1.2 billion. Is that fact or fiction? After all, I cannot see where that £1.2 billion has been reinvested in the NHS.

It may be that many nurses will not pay back their loans because, if they stay in the nursing profession in the health service for 30 years, they are unlikely to earn enough to do so, but what of the effect on the potential recruits? It is a long time since I started nursing, but in Scotland we could start nursing at 17 and a half. I recall that two or three out of that first year could possibly have been referred to as mature students; the rest of us were all youngsters. Similarly, in my post-registration training south of the border, we had a nursing cadet scheme where most people came in at 16 as cadets and commenced nurse training at 18. Mature students were almost unknown. It is a totally different situation today. Many students are mature or have family responsibilities. I cannot see how they would want to come into the profession now, with the risk of being saddled with a student loan for many years to come. It is a perception thing, and it is extremely important that the Government keep the matter under review and carefully monitor it.

There is one bit of good news that I would like to touch on, and that is the development of the new nursing associate. The measure is long overdue and, provided that it is developed correctly, it will give an opportunity for many who do not want to do the full degree course to become a registered nurse. That is something that my old union, the Confederation of Health Service Employees, campaigned for at the time of the ending of enrolled nurse training, but it did not happen. Still, what goes around comes around.

My concern here is that we do not return to the situation that we had with enrolled nurses and that the substitution of the nursing associate for the registered nurse becomes a fashionable thing, particularly with pressures on finance. The awfulness of what happened in Mid Staffs is not so long ago that it can be erased from health boards’ corporate memory. We know that the fewer the registered nurses, the greater the mortality risk. I do not want to see any substitution here of registered nurses by nursing associates.

I just wish we could stop this nonsense of nursing associates already being referred to as “associate nurses”. It is important that they are going to be registered by the Nursing and Midwifery Council, but a nursing associate is not a nurse. I wish we could regulate and protect the word “nurse”. The phrase “registered nurse” is protected, but the word “nurse” is not. We have health trusts applying the label “advanced nurses” to people who have never seen a bit of nurse training in their lives. That should not happen, and it is something I would like to see the Government getting a grip of.

My time is up, but there are many issues that have to be addressed if we are to resolve some of the issues that have been raised in today’s debate. I forget who it was who said it, but if these things are not dealt with then rivulets of discontent could reach flood proportions. I hope not—we have been there in the past and I do not want to see it in the future. There is much work to be done, and I hope the Government can get a grip on some of these difficult issues that we face.

NHS: Wound Care

Lord MacKenzie of Culkein Excerpts

Wednesday 22nd November 2017 Lords Chamber

[Lord MacKenzie of Culkein (Lab)]

My Lords, I am delighted that my noble friend Lord Hunt of Kings Heath was able to secure this important short debate, which was so ably introduced by my noble friend Lady Wheeler. As a former nurse, I find this subject of obvious interest. As someone who was at the receiving end of suboptimal wound care some nine years ago, and has residual problems to remind me every day, I find that interest reinforced.

Wound care is no longer part of what many years ago used to be called basic nursing practice. Obviously, I expect that all registered nurses will know a lot about wound care—but nowadays it is much more than that. Before treatment there have to be proper diagnosis and proper identification—or perhaps I should say classification—of the wounds. There are many types of wounds: surgical incisions; abrasions; granulating or overgranulating wounds; and diabetic foot ulcers and ischaemic leg ulcer wounds, about which we have already heard quite a bit in the debate.

One of the least excusable wounds to me, as a nurse, is the hospital-acquired or care home-acquired pressure sore. It should never be forgotten that sloppy, incorrect care of a tiny wound, as in a jugular vein cannulation site, can lead to sepsis, with all the horrors that follow, such as acute kidney injury. I know because it happened to a relative of mine very recently.

There is no doubt that the care of wounds is staff-intensive, extremely costly to the National Health Service and, not least, costly to the patient in terms of pain, infection and immobility. Wounds not healed within, say, six weeks can be defined as chronic. There are many factors which delay and impair wound healing, including: underlying disease; reduced blood supply; infection; malnutrition; poor patient compliance; and, indeed, smoking and alcohol. There are more, but I am not going to list them—except to say that one of the most important is inappropriate or poor wound management.

It is here that I will speak about the role of the tissue viability nurse. That nurse specialist comes into their own in cases of wound management. They have an important role in clinical practice. Their skills are important so that there is correct diagnosis and classification, which in turn will lead, one hopes, to the correct treatment—there are huge variations in the types of tissue damage in different wounds. Is the wound clean? Is there debris? Is there infection? Is there pus, a lot of exudate or a lot of necrotic tissue? All these issues have to be identified before treatment.

The tissue viability nurse also has an important role in prevention; in education; in research; in working with other National Health Service teams, including pharmacists, and, ideally, outside the hospital with, for example, community staff, care homes and hospices. It is, or should be, part of the tissue viability nurse’s role to educate senior finance and procurement staff about what really works in wound care. Tissue viability nurses, individually or in teams, have the capacity to reduce trauma for patients and mitigate the huge costs to the health service, but there are too few of them, too few specialist doctors and far too many protocols. As my noble friend Lady Wheeler said, there is a vital need for a nationally agreed and properly resourced strategy to improve prevention and, where prevention fails, to improve the quality of wound care and thus reduce costs.

I turn to dressings. There appears to be increasing pressure to redefine what we used to call “cost-effective treatment” in relation to wound dressings to mean the cheapest—or, in the jargon currently used in procurement, those said to be “clinically acceptable”. That is not necessarily the best way to reduce costs. Dressings classified as “acceptable” cannot always be those that are clinically indicated and appropriate. If healing is compromised and delayed, that which might be acceptable to accountants becomes, in fact, the antithesis of what is really cost effective. Doctors, tissue viability nurses and other nursing staff need to be able to access the treatment which is essential to promote the best outcome —for the sake of the patient and of the service.

I have no problem with cheaper generics when it comes to paracetamol or the many other drugs which have exactly the same formula as the more expensive branded versions. This is not so in the highly specialised field of wound dressings and treatment. Cost must not be the primary driver.

My daughter, who is involved in clinical teaching, tells me that programmes that have been developed to carry forward professional development in her trust are now severely curtailed by the massive reduction in the funding for continuing professional development. That includes development of courses on issues such as wound care.

We are seeing reductions in opportunities for training, the drive for the cheapest possible procurement, the huge workload pressures on nursing staff in hospitals and, even worse, in the community, as evidenced by the massive reduction in the numbers of district nurses. All those factors together must militate against the good developments in wound care. There cannot be any argument against the need for a coherent national strategy if we are to reduce poor outcomes for patients and reduce the costs involved.

I hope that this short debate will reinforce the seriousness of this matter to the Government and give the Minister the opportunity to tell the House what plans there are to increase, for example, the number of tissue viability nurses so that there can be more support, not just for staff in hospitals but for hard-pressed community staff and for nursing and care homes. Will the Minister say how the important matter of wound care is to be taken forward? Will there be a new coherent national strategy? I very much look forward to his response.

National Health Service

Lord MacKenzie of Culkein Excerpts

Thursday 14th January 2016 Lords Chamber

[Lord MacKenzie of Culkein (Lab)]

My Lords, I, too, thank my noble friend Lord Turnberg for securing this important and timely debate, and join in the welcome of the noble Baroness, Lady Watkins of Tavistock. It is good that we have another nurse in this House. In my memory it is the first time in some 16 years that we have had three nurses speak in quick succession in a debate. If anyone with any influence out there is listening, we need even more nurses in this place.

It goes without saying that unless we have a highly skilled and well-educated nurse force there are implications for the future of the health service. But now, without any consultation whatever with the Royal College of Nursing, the Royal College of Midwives or UNISON, we are hit with the Chancellor’s CSR announcement. It is the same sort of attitude that my noble friend Lord Winston referred to so far as the medical profession is concerned. There was no reference whatever to the nursing and midwifery professions about the changes to the pattern and funding of nurse education. That announcement has come out of the blue and provides that, from 2017, student nurses, midwives and others will have to pay their university tuition fees and that, at the same time, their bursaries will be scrapped. Thus will end free education for nurses and midwives. The justification is to allow more applicants to get into university—to allow more to get past the so-called cap on places. Listening to the Chancellor’s announcement, you would have thought that the dreaded cap was nothing whatever to do with the Treasury and the restrictions on funding for university places for student health professionals.

There are few, if any, graduate professions as ill rewarded as nursing, so I am not sure how the Chancellor thinks that his plans can work if potential nursing students are to be faced with what for many will be career-long indebtedness of perhaps up to £50,000, to be paid back immediately on qualification from a miserable starting salary of about £21,000. Quite clearly the Chancellor and the Department of Health have been seduced by the Council of Deans of Health and Universities UK because the whole plan seems to be more about income for universities and, at the same time, savings for the Government than it ever has to do with workforce planning and the alleged possibility of more university places.

In a Written Answer to me the Government admitted that they do not collect data on how many student nurses leave university because of financial reasons, yet they now pray in aid the fact that there will be more money available from loans, as if the bursary system was a primary retention problem. To look at the figures, if the present percentages at universities are replicated, then many of the 10,000 so-called extra places will go to increasing numbers of midwifery and other health profession students. It will leave probably 6,000 extra places for nurses—2,000 per annum. Unless my maths is badly wrong, we will potentially have some 22,000 nursing students per year. That is the better part of nearly 3,000 fewer places than we had under Tony Blair’s Government of some 10 years ago. As with so much, we had the numbers right then, and we need to get back to that Labour figure if we are serious about tackling nurse staffing in the NHS.

Very close to home, a member of my family who has a number of degrees, is a skilled practice educator and teaches at university from time to time was until very recently still paid as a staff nurse. That is not a reward for 30 years’ continuous practice and education that will encourage nurses to take on a huge debt to come into our profession. With the greatest respect to the Minister, for whom I have the highest regard, we have either to start to pay nurses properly for their duties and responsibilities or else we have to do a quick U-turn if we are to get more students into university. We have to look carefully at what we are doing here and we have to work with those who represent the nursing and midwifery professions, which at the moment the Government have manifestly failed to do.

NHS: Reform

Lord MacKenzie of Culkein Excerpts

Thursday 16th July 2015 Lords Chamber

[Lord Prior of Brampton]

I was interested by my noble friend’s comments about waiting until the following Monday when she has been in hospital. That is a good illustration of why we want to bring in seven-day services. My noble friend might be interested to read the report in Future Hospital, written by the Royal College of Physicians, that came out a year ago. I think that we will see over the next few years a significant change in the way that our hospital consultants are trained and deployed, and more generally what is called in America hospitalists, who can have a broader range of disciplines.

When it comes in, the new contract will enable us to differentiate payment for those consultants who are working more anti-social hours, such as A&E consultants who will have to work much more regularly out of hours than others. It will enable us to identify those consultants who may be on call but are more likely to be summoned in, like those that my noble friend just mentioned, at short notice. Depending on the surgical specialty, the on-call requirements can be much more demanding than others. For example, this is more the case if you are a vascular surgeon than if you are a dermatologist, who do most of their work in normal time. I take on board what my noble friend says.

[Lord MacKenzie of Culkein (Lab)]

My Lords, no one will disagree with the concept of a seven-day-week health service. I was at the wrong end of a catastrophic surgical error that meant instead of one night in hospital I was there for six months. I dreaded weekends, and I dreaded them even more if there was a bank holiday attached, as has already been mentioned.

If we want to deal with party politics, can I explode the myth that has been peddled that the Labour Government were responsible for the five-day-week approach, because of the consultant contract? For many years I was a theatre nurse. I never scrubbed on a Saturday or a Sunday in the 1960s or 1970s. Hospitals ran on a five-day-week then, so it is quite wrong to suggest that this is all the fault of the consultant contract a few years ago.

I agree with my noble friend Lord Hunt of Kings Heath. If we want to have endoscopy suites open, radiography, radiologists, and nurses manning theatres and recovery rooms on Saturdays and Sundays, we must have more of these professions. If we do not, we shall diminish them on Mondays, Tuesdays and Wednesdays, and we will not be much further forward. Will the Government commit to increasing training places for all of these professions, together with consultants such as radiologists, as I suspect that we have many fewer of those than in most other developed countries?

[Lord Prior of Brampton]

Interestingly, the number of consultants has increased very significantly over the past 15 years across not all but most specialities. The noble Lord refers to dreadful weekends, and how he dreaded them, particularly bank holidays. That is really why we are here today, so that in future patients like him do not dread them.

If I indicated earlier on that I blame the 2003 contract for the difference between five days’ and seven days’ working, and if that was the implication of what I said, I withdraw it. What I meant to say was that I felt that that contract to some extent de-professionalised the profession.

Care Bill [HL]

Lord MacKenzie of Culkein Excerpts

Monday 21st October 2013 Lords Chamber

[Lord Warner]

My Lords, I support both the amendments. They are not alternatives but complementary. I want to start briefly from where we are. The issue of staffing numbers, ratios and skill mixes is just a black box as far as the public are concerned. It is something that goes on within the NHS. This has some relationship to our earlier debate about failure. It is often very difficult for outsiders—and I include regulators as outsiders—to understand what is going on in institutions, particularly acute hospitals. This issue is not peculiar to hospitals; it is even more of an issue for community services, in some ways.

I would like briefly to share my experience as the chairman of the provider agency in London. If your Lordships think that things are bad in some hospital services, try the community services. When we started to poke around in the community services, we found huge variations in the staffing levels for populations with particular conditions. There were massive variations in the face time that clinical staff spent with their patients. We have issues in community services which are often probably more dangerous and less reassuring than we have in some of our hospitals. If we are to have such amendments to the Bill, it is clear that they must relate not just to acute hospital services.

We are not going to get public understanding about when hospitals are failing or unsustainable without a better sense of public education about what a safe level of staffing is to give the reassurance that you are going into a facility which is safe. I added my name to Amendment 159 because it opens up the issue of putting into the public arena some data and reassurance about what a safe level of staffing is for some of these services. It can then be prayed in aid by both commissioners and providers when there are issues about whether a unit is sustainable. We often talk about unsustainability as a financial issue, but it is often about staffing issues—the sheer inability to get a safe group of staff together to run the institution. One acid test of why a place is unsafe is the number of bank or agency staff in a unit, who come and go at ever-increasing frequencies. Public understanding of what is going on in these hospitals seems critical to public reassurance.

Nobody wants to put staff numbers into the Bill, but we need something better than we have now to give the public some idea about the staffing levels and skill mix in what are, at the end of the day, relatively closed institutions. It is difficult for the public to understand what is and is not safe without more data, and that would make it much easier to hold boards to account. Amendment 159 would make it clear that the boards of trusts need to come back continually to what they are providing to the public in the safety of their staffing levels. Amendments 144 and 159 certainly do no damage to the Bill. They strengthen it and it is much more in the interests of the public to have this data available locally, as the noble Baroness, Lady Gardner of Parkes, has said, relating to specific establishments and institutions.

[Lord MacKenzie of Culkein (Lab)]

My Lords, I also support both amendments. It seems to me, as a nurse, to be a self-evident proposition that having safe staffing levels and the correct skill mix, taking into account dependency and acuity, is the right thing do. Anyone who has listened to the debates in this House on various Bills dealing with health and social care over the past few months knows that it is an enormously complicated issue. However, we must bring it back to this level of patient safety and the duty of providers to provide safe staffing levels and the correct skill mix. If that is not done, all the other things we talk about will be in vain and we will end up with more reports, more inquiries and more problems.

As has already been said, it is incumbent on Governments to take account of all these things: the Francis report, the review into Winterbourne View and some of the recommendations in the excellent report produced a few months ago by the noble Lord, Lord Willis. It is vital that we get this right. At a time when financial pressures will force authorities to look at diluting the numbers of trained nursing staff and trained staff in the community and replacing them with healthcare assistants or support workers with hugely varied levels of training and experience, it is absolutely right that we get the correct level. As has already been said, both of these amendments can only add to the Bill and take nothing away from it.

[Earl Howe]

My Lords, I hope that I can give noble Lords considerable reassurance on the Government’s position on these important issues. It is almost axiomatic that safe, high-quality care is dependent on people and that right-staffing, in terms of numbers and skills, is vital for good care. The importance of having the right staff with the right skills and in the right numbers is central to the delivery of high-quality care. Where staff are stretched because they are too few in number, corners will be cut, with inevitable adverse consequences for patient care. Equally, where staff do not have the right skills to carry out their tasks, the quality of care will suffer.

Patient safety is the first priority, and safe staffing levels really matter. The quality of care provided to patients is ultimately the responsibility of the leadership of provider organisations. It is their responsibility to ensure that they have the right staff with the right skills in the right place at the right time in order to provide high-quality care. In the final analysis, it is for hospitals themselves to decide how many nurses they employ, and they are the best placed to do that. Nursing leaders have been clear that hospitals should determine and publish staffing details and the evidence to show that staff numbers are right for the care needs of the patients that they look after.

Although local providers are best placed to do this based on local need, we expect them to look to authoritative guidance and evidence-based tools and learn from best practice to deliver cost-effective and safe care. We recognise that there is a need for national action to ensure that local organisations meet those expectations. As a result of the national nursing and midwifery strategy and vision published in 2012, Compassion in Practice, a considerable amount of work is going on across England to ensure that providers use evidence-based tools, using acuity and dependency measures to set staffing levels, and for boards to publish these staffing levels on a regular basis.

I want to explain what we are now doing to build on that work. First, the Chief Nursing Officer, supported by the National Quality Board, is developing guidance for the system, including a set of expectations, to support provider organisations in securing the appropriate staffing capacity and capability for nursing, midwifery and care. This guidance is being developed with the intention of ensuring safe patient care and that patient outcomes are not compromised. It will include expectations on transparency and publication of information on staffing.

This guidance is being developed jointly by the statutory organisations responsible for quality across the NHS, which are brought together as part of the National Quality Board and which include the Care Quality Commission, Monitor, the NHS Trust Development Authority and NHS England. It will be published next month. I can therefore only agree with the intention behind the amendment that providers need to be open and transparent about their staffing numbers. The positive news is that action is already in place to ensure that this happens.

--- Later in debate ---

[Lord Patel]

My Lords, I have put my name to Amendment 158. I also thank the Minister for pulling a rabbit out of the hat, so to speak. However, I am not as gobsmacked as the noble Lord, Lord Willis of Knaresborough, because I have lost count of the number of times and days in this Chamber that we have debated the need for training healthcare support workers. I am at least glad that it has now paid some dividends.

I am also glad that the noble Earl said that Health Education England would take the lead on this, and will involve the NMC in devising the standardised training programmes, because it has the expertise to do it. I agree with the noble Lord, Lord Hunt, and others that this inevitably means there will need to be some sanctions for those who do not fulfil the requirements for training and therefore fail to be regulated. I am not sure whether that is for this Bill or subsequently, but it will inevitably lead to that. However, I thank the noble Earl for his amendment.

[Lord MacKenzie of Culkein]

My Lords, I join in the congratulations to the Minister on his words this afternoon. For a long time I have felt that trying to get some movement on this issue of education and training for healthcare assistants was rather like the sufferings of Sisyphus pushing that stone uphill. Fortunately, I was wrong and the debates that we have had on this issue over the past few months have clearly borne fruit.

I join the noble Lord, Lord Willis, in saying that the permissive “may” in Amendment 153 should be changed to “must”. It is extremely important that that happens if at all possible. For me, regulating healthcare assistants has been an issue since the long preparation for Project 2000 and the eventual demise of the enrolled nurse, leaving the gap which has now had to be addressed in this way.

The Minister has always been careful to say that the Government do not have a closed mind on regulation. I hope that that remains the position because, given the position we have now arrived at, it is inevitable, for the reasons that my noble friends Lord Hunt and Lord Warner have given, that regulation will come some day. To coin the current phrase, it is a can that has been kicked down the road long enough. We ought to stop kicking it and get there sooner rather than later.

I heard the Minister say in the past that regulation is not a guarantor of good care. That, as far as it goes, is true, because if it was a guarantor, there would be no poor practice or misconduct in any profession. That is not an argument against regulation for all the professions that are properly regulated to safeguard the public. I hope that an open mind will be kept on this and that we can come back to the issue of regulation, which is now inevitable. Having said that, I am grateful and delighted that we have made the progress that we have today and again I thank the Minister for his persistence in this matter.

Care Bill [HL]

Lord MacKenzie of Culkein Excerpts

Wednesday 12th June 2013 Lords Chamber

[Baroness Emerton]

I rise to speak to Amendment 59 which includes the Chief Nursing Officer in the list of those participating in the authority. I thank the noble Lord, Lord Hunt, for his words on this point. I have raised the issue of the importance of evidence-based practice and the need for us to be able to develop research within the nursing profession where, to date, it has not been at the forefront of progress. Having the Chief Nursing Officer taking part in the work of the research authority, although perhaps not in its detailed content, will assist in raising the profile of the importance of research. It may well be delegated from the CCGs to the health trusts, where we may see professors of research, which will then encourage research throughout. The nursing profession is the largest single workforce within the NHS. It is important that we promote the idea and development of research by having the Chief Nursing Officer in the list.

While on this subject, it is encouraging to see the list in the Bill. When the Health Bill was introduced, health education was not included and the membership of Health Education England was not clearly set out. Although it does not relate to research, I would like to mention the importance of having an executive nurse on the health education board, because there is an executive doctor, but not an executive nurse. Perhaps I can return to this when we come to Report.

[Lord MacKenzie of Culkein]

My Lords, I rise briefly to speak to Amendments 58C and 59. The noble Lord, Lord Hunt, and the noble Baroness, Lady Emerton, rightly referred to including nursing in the Bill.

As the noble Baroness, Lady Emerton, said, the practice of nursing these days is underpinned by research. Of necessity, nurses are involved in research, and it must be right to include the Nursing and Midwifery Council and the Chief Nursing Officer in the Bill.

In debates on the Bill, we have heard a number of times that it is all too easy to exclude nurses. Whatever body they should be represented on, they so often are not there. I can go back, probably the better part of 40 years, maybe more, to when I once had the temerity to ask my matron to raise something at the hospital management committee. She said to me, “I’m sorry, nurse, I can’t, because I only attend by invitation of the group secretary”.

There have probably been about 20 reorganisations—I forget how many—since those days. However, all too often the situation has not changed and nurses remain excluded. The reason for excluding them, very often, is that the legislation does not cover it and therefore it is not necessary for nurses to be included. We now have the opportunity. Let us have nursing in the Bill. If we are going to have lists, as the noble Lord, Lord Hunt, said, I want to see nurses in it. I hope that the Committee will support that.

[Baroness Cumberlege]

My Lords, I strongly support the amendment tabled by the noble Baroness, Lady Emerton, and am very interested in what the noble Lord, Lord MacKenzie, said. It seems that, over the years, nursing has been the poor relation when it comes to promoting the medical profession. Both are so important, and they have to work together. If the Francis report tells us anything, it is that we need to ensure that both are of a very high quality.

I asked the Royal College of Nursing today to give me some examples of research that nurses are doing. I will not try the patience of the Committee by going through them, but it gave me three extremely good examples which undoubtedly improve the quality of patients’ experiences and recovery rates. This work is going on, but it really should be of a higher profile. It should be applauded and used. I appreciate very much what the noble Lord, Lord Hunt, said about lists, which are a trap that I remember falling into on occasions when I was a Minister. I suspect that the noble Earl will tell us that we want to have it both ways: sometimes we want things in regulations because that is more flexible and at other times we want them in the Bill. This is something of a dilemma, but if the medical profession is in the Bill, nursing certainly should be as well.

I also strongly support Amendment 60, in the name of the noble Lord, Lord Turnberg. I was very interested to read about the delays that occur through not getting together all the different organisations that are going to be involved in a single trial. According to Kidney Research UK, the time taken in one trail to receive R&D permission varied from around five weeks to 29 weeks. A study of stroke survivors took between one week and 35 weeks to receive permission from the NHS trusts involved. The time taken between submission of site-specific information and NHS approval ranged from five weeks to 50 weeks for a multi-centre trial comparing two types of emergency intervention for ruptured aortic aneurysm. This is totally unacceptable. Those who are promoting the research, and are the leaders in it, must get so frustrated when the bureaucracy will not allow them to go ahead. We need good research. It makes a huge improvement to patients’ lives, especially, of course, when it is translated to the patient in the bed, as it were. Anything that we can do to speed this up and to put pressure on to ensure that the time lags are not as long as this would be very much welcomed.

Nursing Quality and Compassion: The Future of Nursing Education

Lord MacKenzie of Culkein Excerpts

Tuesday 11th December 2012 Grand Committee

[Lord MacKenzie of Culkein]

My Lords, I am grateful to the noble Baroness, Lady Emerton, for putting down this question to the Government today.

It is apposite that we should have an opportunity to discuss the matter of care and compassion in another week when issues have again been raised about the quality of care, not least by the awful story told by Ann Clwyd MP at Prime Minister’s Questions last week. There is a very similar on the comment page of the Nursing Times of 4 December, written by a senior lecturer in the Faculty of Health and Wellbeing at the University of Cumbria. It has not been a good week for the nursing profession, not least with the release of the final report on Winterbourne View yesterday.

As a nurse, and as someone who has worked for nurses and nursing for most of my working life, I feel deeply saddened by the adverse publicity that my profession is now getting. This stuff will run and run; it will take a lot of time and hard work to mend the damage that has been done.

The question before us today is about the report of the Willis commission. The noble Lord, Lord Willis of Knaresborough, deserves our thanks for undertaking this very important piece of work. I would disagree with little, if anything, in the report. In the introduction to his report the noble Lord, Lord Willis, said that,

“there has been insufficient political or professional will”,

to implement past recommendations. He expresses the hope that that will not be the fate of his report. I sincerely share that hope. As has already been asked of the Minister, I hope that he will tell us that this time we will go down the right path.

The nursing world has in many respects changed out of recognition since the days long ago when I commenced my training. However, some things have not changed. It is not new that there are brilliant nurses, good nurses, some who are less good and some who are not suited to the profession. In my student days, when most started training at the age of 18, many of these were eased out during training.

Neither is the debate new about whether nurses are the finished article on registration. I can remember nurses who thought they had arrived and done it all on the day they completed their training. I much preferred the view that one really started to learn only after one qualified and took some measure of responsibility and accountability.

The issue of fitness to practise on registration is often discussed, but it must depend on the appropriateness and quality of education and the quality of teaching on placements followed, after graduation, by good preceptorship and clinical supervision. I have a relative who is a lecturer in a school of nursing and midwifery in a university. She tells me that they are not allowed to go into hospitals and wards to see what their students are doing, although I understand that teachers in some other universities can; indeed, I know they can because one used to appear at my bedside in uniform, complete with Barts badge to supervise what her students were doing and procedures. However, I gather that some not being allowed to supervise any work is something to do with universities and vicarious liability. That underlines my view that we need a return to clinical teaching. Pressures on ward sisters and mentors are such that there is a gap here. It is not necessarily the case, as some academics argue, that clinical teaching disrupts the natural process and flow of care.

I will touch briefly on workforce planning and commissioning. The Willis report underlines the difficulty in getting good statistics and the risks of workforce planning being left to local employers. I endorse the commission’s view that there must be a well developed UK oversight. The future cannot be left to short-termism and localism.

My union, the Confederation of Health Service Employees, supported the Project 2000 proposals to move away from apprentice-type training and into the higher and further education sector. We also supported the ending of enrolled-nurse training, as it then was; I still have the scars on my back from trying to further that argument with many enrolled nurses, including my own daughter. What we did not support was that there should be no other form of regulated training for staff that would in the future carry out much hands-on care—what I still prefer to call nursing care.

I spent many months travelling the country addressing meetings on Project 2000 and the ending of enrolled-nurse training, and advocating COHSE’s policy of an entirely new second level that did not have the problem of confusion of roles between the first and second levels as there then was. We wanted a new second-level support nurse trained to an agreed standard of about a year or so. Apart from the support of a couple of regional nursing officers, we ploughed a lone furrow. There was no real support from the leadership of the profession at that time.

The quite proper drive to enhance the status of the nursing profession has left us now with a plethora of support workers of varying training, or little or none, together with a multitude of job titles, delivering a great deal of nursing care. As the commission of the noble Lord, Lord Willis, puts it, that care is delivered with greater or lesser supervision. We need to do something now about the training of support workers. In reality, with the demographic pressures and financial pressures that there are going to be, there will be fewer degree-level nurses and more support workers. That much care is not going to be delivered by nurses themselves.

It is not part of my purpose to rubbish support workers. Many, in my experience, are excellent, but they need to be trained to an agreed standard, and they need to be regulated and registered. Some progress is being made—I have no doubt that the Minister will reinforce that—but it is not enough. I know that he has heard me on this subject before, but it is wrong and unconscionable that nurses have to accept responsibility for staff whose abilities and competencies cannot be relied upon.

There are a number of issues facing us. Some of these are cultural, although I personally find it difficult when I hear of curtains not being drawn around a bed. The noble Baroness, Lady Emerton, will well remember that we were taught to do no procedure without having first pulled the curtains around the bed and telling the patient what we were going to do. Nobody ever did anything without that ringing in their ears. It is not difficult to do, and not difficult to teach.

My final plea is that the ward sister should be supernumerary and accountable, and that senior management should be accountable because it is not always the staff at the sharp end who should carry the can. We need to get the education, the training and the skill mix right, and must not leave everything to localism. There has to be some national responsibility and accountability. I hope that nurse leaders will continue, as I know that they will, to fight to restore the image of our profession. If not, there will be more inquiries, more scandals and, perhaps, a royal commission. I hope that we do not get that.

Social Care

Lord MacKenzie of Culkein Excerpts

Thursday 29th November 2012 Lords Chamber

[Lord MacKenzie of Culkein]

My Lords, I join in the thanks to my noble friend Lady Pitkeathley for securing this important debate and for her most eloquent speech. This debate is about the ambition to integrate health and social care. I am not, I think, one of the usual suspects because nurses of my generation were not very good on social care. One of the joys of being in this House is that one is always on a learning curve.

The integration of health and social care is a laudable objective and whether it succeeds, as we all hope it will, will depend on a number of important matters. Are NHS trusts, local authorities, clinical commissioning groups and health and well-being boards going to work well together, or will a new commissioning and marketisation framework, together with the existing barriers, lead to fragmentation and diversification in care services and perhaps disrupt any consensus? Will we get the innovation that we need? That must be the way forward. Or could it be that without proper regulatory guidance and funding, any new social service will end up like the present model—best described as patchy, incomplete and with a lot of staff who are poorly trained and paid, and unregulated. Will there be multiprofessional input into clinical commissioning groups? Will nurses be properly involved in hospital discharge policy and the development of community care?

The elephant in the room is: will there be sufficient money? It is fine to talk about efficiencies but so many so-called efficiencies are, in reality, not showing any demonstrable improvement in care. All too often they are a euphemism for cuts, rather than savings being reinvested into services. There are dark clouds on the horizon. The worst scenario, if I can repeat a phrase used a few minutes ago, is a perfect storm of demographic pressures combined with cuts in central grant support, council tax freezes and NHS organisational change, which could lead to a worsening of social care and further reductions in services, leaving the Government’s aspirations and policy in tatters. A lot of the money from the NHS that is designed to encourage joint working is, in reality, being used to avoid further cuts in services. That is a real concern.

I am also concerned about what might be said to be an auction race to the bottom, with providers appearing to win contracts by bidding at lowest cost rather than on quality. For example, when the Serco conglomerate took over the excellent Suffolk Community Healthcare, it was predicted by UNISON that there would be job losses. That was, I understand, denied. Now Serco, following its usual pattern, has proposed cutting more than one in six posts. That is how one can underbid an already good provider by some £10 million. The combination of financial restriction and the delivery of quality care is, to say the least, extremely difficult.

In domiciliary care, there is much reported worry, and much has been said about it today. I fail to see how we can have dignity, client choice and safeguarding with the present “time and task” system, which is so often the pattern. A recent UNISON survey showed a situation for many care staff which rather reminds me of the low-cost airline model of employment, with staff under pressure and paying for their uniform and training, quick turnarounds and wages varying every week. As the noble Baroness, Lady Gardner of Parkes, said, many of these care staff are not being paid for time travelling between visits and have zero-hours contracts. There is one difference: easyJet would not tolerate for one moment its customers being treated in the way that vulnerable elderly people or people with disabilities are being cared for in short, 15-minute visits. It is not possible in so many domiciliary care settings for there to be proper adherence to safeguarding principles and practice, and much too often the possibility of the client exercising choice is not a realistic proposition.

The situation in many care homes is little better. Nurses I speak to report that there are intolerable staffing pressures with often poorly trained staff. When things go wrong, the staff are made scapegoats when the resources are not being provided and managers and home owners are not held accountable.

The pattern is repeated for nurses working in the community. A recent Royal College of Nursing survey showed that 6% of respondents said they could deliver the quality of care that they wished to, and 75% of community nurses indicated that pressure on the nursing team had increased, leading to considerable concern about their capacity to protect adults and children at risk. Much of this problem emanates from cuts in social care budgets.

Who picks up the pieces? We have already heard today, and UNISON and the RCN remind us, as does the King’s Fund, that it is the National Health Service. Pressures on social care budgets lead to increased emergency admissions and pressures on A&E departments and continue the revolving door, with which we are so familiar, delivering inappropriate care in the wrong setting. That is not good for the National Health Service or for patients who are so often denied, for example, the prospect of good palliative care at the end of life at home or in a hospice.

The health charity sector is also suffering at a time when the need for its contribution has perhaps never been greater. There is no doubt that the Government will be looking to it to pick up more of the pieces as funding from local authorities and NHS commissioning is cut. Smaller charities, in particular, are affected, with the probability that staffing will be reduced or, as in the case of that great charity, Turning Point, that staff will be dismissed to be re-employed on poorer terms and conditions. That is an unenviable choice for dedicated staff and for the charities that do so much to fill gaps in our health and social services.

Social care is a complex subject. There are many areas one could speak on, for example, housing and so on. Others have spoken eloquently on them, so I shall conclude by mentioning the Local Government Association’s “Show Us You Care” campaign. I will not repeat all the details or even the bullet points. The Government know full well what that campaign is about. It is about the current funding problems, the future of social care, fairness and the ability in the future to maintain roads, libraries, swimming pools and so on.

This leads me neatly to the Dilnot commission, which has been much mentioned this afternoon. My noble friend Lord Warner said that it may not solve all the problems, but I think it will go some considerable way and would be a good start. I hope that the Minister can tell us when we will hear about the Government’s proposals following on from that excellent piece of work. There were reports in yesterday’s press that we might hear something in the near future, and it would be wonderful if the Minister could confirm that that is the case.

I again thank my noble friend Lady Pitkeathley, and I look forward to what the Minister will tell us when he winds up.

Health and Social Care Bill

Lord MacKenzie of Culkein Excerpts

Monday 19th March 2012 Lords Chamber

[Lord MacKenzie of Culkein]

My Lords, as a nurse I am always delighted to support the noble Baroness, Lady Emerton, and I particularly support this amendment.

I had hoped that the House might have agreed the need for statutory regulation and registration for healthcare support workers, but the Government should at least accept this amendment. It provides for a code of conduct, for mandatory training, which must be to an agreed standard, and for a requirement to have undertaken an assured training programme before one can enter the voluntary registers that are to be set up. These things should all be in the Bill; they are necessary to protect the patient and the public.

Training, in my view, has to be mandatory; it cannot be left to the whims of employers to decide how much or how little training to give to healthcare support workers. I know from nurses, including my step-daughter, who is a registered nurse, that some of that training is good, some of it is patchy and some of it is shockingly poor. Some of it is supernumerary today, on the team tomorrow; see a procedure today, carry out that procedure tomorrow. That old system of training has no place in the modern delivery of nursing care, but it is what many healthcare support workers have delegated to them.

The Minister knows my views about voluntary registers, but I have no wish to see them fail. If they are to succeed, every effort must be made to ensure that those who are eligible get on to these registers. He will correct me if my memory is playing tricks on me, but I seem to recall him saying at an earlier stage that employers could require someone to be on a voluntary register before appointment or promotion. I have no quarrel with that if we are properly to protect the public, but I want to know whether an employer can do that. If, say, there are two candidates for promotion with very similar training and experience on their CVs, but one is on the voluntary register and one is not, will the employer be able to refuse to see the person who is not on the voluntary register? I wonder what an employment tribunal might make of that.

I hope we can have an assurance that employers will be able to discriminate in this way, because I am concerned that everyone who should be on the register is on it. We know that rogues and rascals and those who are less than suitable are the ones who are not likely to want to be on a voluntary register, which is why I prefer the other course. However, we are where we are and I hope that the Minister can at least reassure us on this point.

[Baroness Masham of Ilton]

My Lords, I have my name to the amendment. During the passage of this Bill, some of us have been trying very hard to improve the care of vulnerable patients in hospital and in the community. I felt healthcare support workers should be registered and regulated, as many vulnerable patients, being frail and elderly or disabled in many diverse ways, have to rely on their carers. Your Lordships have heard that patients have been put at risk or died through neglect or assault in care homes and hospitals up and down the country. Many people wait in anticipation for the result of the review of the Mid Staffordshire Foundation Trust. This must not be covered up; lessons should be learnt in memory of the hundreds of patients who received poor care, were neglected and died. Surely it is our duty to try to help rectify this deplorable situation.

I have every admiration for the Minister, who has worked tirelessly over this Bill, but I do not agree with him that nurses who have been struck off their register can go back to caring for patients as unregistered healthcare assistants. We are exposing the most vulnerable in our society to greater risks and poorer care if we do nothing to prevent struck-off nurses continuing to work in a caring profession. This amendment is a compromise, but even so it has a very important part. Subsection (2) of the proposed new clause in the amendment states:

“The assured training programme shall be mandatory for all new health care support workers from 1 April 2013”.

Not to train people who care for vulnerable patients is deplorable. Last year I was involved in a case of a person living at home and using a respirator. The patient was left brain damaged when the agency nurse turned off the wrong switch. Adequate, appropriate training should be given; in that case, it was a health care worker who was also a nurse.

Many disabled people are living in the community, which is good, but many of them use technical equipment that needs training and understanding, such as hoists, pressure mattresses, peg feeds, catheters, complicated electric wheelchairs, ventilators, nebulisers, diabetic management, colostomies, adapted vehicles and many other complicated devices. An assured training programme should include where to place a patient’s food and drink and to assess whether the patient can feed themselves. If not, the healthcare worker should know how to do this; how to wash and bathe and deal with personal needs such as toileting; how to prevent pressure ulcers; moving and handling; and complications with patients who have problems and may be difficult and have a problem communicating. There are many needs, but kindness and common sense should prevail.

If the Minister and the Government do not agree with this amendment, it will mean they do not understand the needs of vulnerable patients’ care. If training is mandatory, I am sure employers will take notice.