Health and Social Care Bill

Lord Newton of Braintree Excerpts

Tuesday 13th March 2012 Lords Chamber

I have set out why I do not think that a voluntary register is an answer. I am looking for a commitment that the mandatory training for healthcare support workers will have a strong input from the profession in developing and validating the competencies and outcomes required for healthcare support workers. I also want a commitment to review that education and training to establish the benefits that it has had for patient safety. I beg to move.

[Lord Newton of Braintree]

My Lords, I wonder if I may be indulged again by the House by speaking from an unusual position. I speak against a background—dare I say to my noble friends on the Front Bench—that I have been suitably chastened on the way into the House by being told that yesterday was the first day on which Tory rebels outnumbered Liberal Democrat rebels. There was only one rebel: it was me. Here I stand trembling, yet again.

The spirit in which I approach this is slightly interrogative. I was not able to hear the earlier debate that the noble Baroness triggered, but I am puzzled about the Government’s position on this. I want to ask a few questions. I have no problem at all with tasks being delegated down to the appropriate level. I became Minister of Health 25 years ago, on the day that my noble friend Lady Cumberlege’s report into nurse prescribing was published. Ever since, I have thought that there were a lot of things being done on one level that could sensibly be done at another. I have no problem with the general principle of using healthcare support workers for things that might have been done by others in the past.

However, when it comes to things that are clinical, it is important that people should be trained and properly authorised and registered. That is the key point. Anyone who has been in hospital, as I have on a number of occasions in the past two or three years, will recognise that it is not always easy to work out who does what. I have no complaints about any of the people who looked after me, but it is quite clear that they are at different levels and that one would want to be confident that they all knew what they were doing. The noble Baroness referred to the importance of some of the work that healthcare workers do and we all know that one mistake in medication could have fatal consequences, for example. She referred to the various reports, which I will not rehearse, and she made a number of points that we ought at least to listen to with care.

However, as I said to the noble Baroness in a private discussion, I was a bit sceptical about this because the numbers are potentially huge and we do not want another example of a body being asked to take on more than it can do in too short a time. To some extent, I think that she has sought to meet that in her amendment by narrowing the definition of healthcare support workers to those who are in the clinical area, if I might use that shorthand. That is welcome. But I still think that there may be some problem with the scale of the task if it is imposed at one go. The noble Baroness is aware of my worries about that.

I am also less convinced that a voluntary register could not have a significant effect, with some provisos. First, we cannot have competing voluntary registers with people free to choose the one that they think is easiest. If there is to be a voluntary register, it must be officially sanctioned—I would be grateful for comments on that. If you have one, it might have a significant effect. It would be a brave health trust, once the system was established, that took on healthcare workers who were not registered because of the risk that would arise if something went wrong and the criticism that would ensue. So it might have an effect and I think that we should take account of that.

Even if the Government want a voluntary register and think that it could work, there is a parallel in the field of ombudsmen, which I know something about. That would be to have in the Bill a reserve power to take compulsory registration powers if that proves to be necessary. I am not sure whether that is there or not, but a fallback position might be to have the power to act if the Government’s preferred solution does not work and I would personally press that as a possibility to the Minister.

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The noble Baroness and my noble friend Lord Newton expressed doubts about whether there would be a system for tracking people when they moved. There was also a question from my noble friend about whether there could be more than one register. Current arrangements for statutory regulation do not enable the regulatory bodies to track the movements of individuals; they rely on the self-reporting of changes of job. A voluntary register would be no less able to do that, and indeed could remove people who failed to notify the regulatory bodies of changes. I would say to the noble Lord, Lord Kakkar, and my noble friend Lord Newton that no decision has been made about whether there will be more than one register. As such, I hope I can provide reassurance first that having assured registers means that this is not an easy course of action, in the way that was suggested earlier, and secondly that the professional standards authority could take account of the existence of multiple registers in determining whether to accredit a further register.

[Lord Newton of Braintree]

Will my noble friend give way just briefly? I was at the other end of the Chamber, but I have shifted ends. Leaving aside the point about tracking, on the point about whether there will be one or more register I am conscious that, in the area of ombudsmen, there is experience of rival ombudsmen. Frankly, especially since it is in the choice of the provider not the customer, the providers go to the one who they think will give them the easiest ride. I do not want to see that situation here. Serious consideration needs to be given by whatever means to making sure that, if there is a voluntary register, it is one register and not a choice between a good one, a bad one and an indifferent one.

[Earl Howe]

The key here lies in the standards and the training. If we have standards laid down that are uniform across the piece, I am not sure that having more than one register is a significant issue. As I said, this is something that the professional standards authority is bound to take account of when deciding whether to accredit another register.

The noble Lord, Lord MacKenzie, expressed the view that voluntary registration does not work. The Government’s proposals are for assured voluntary registration. We believe that the effective assurance of the standards of healthcare support workers can be delivered by an assured voluntary register that is underpinned by clear standards of conduct and training and supported by the Nursing and Midwifery Council’s updated guidance on delegation.

The noble Baroness, Lady Finlay, asked how standards will be monitored. We will expect the professional standards authority to assure that any standards set for a voluntary register are appropriate as part of its initial accreditation process. It will keep the operation of any register under review and we will expect it to set out any concerns that it has about standards. The authority will also have powers to remove the accreditation of registers if any of its concerns are not addressed in a timely fashion.

The noble Lord, Lord Patel, asked what criteria would apply in individual cases. In its council paper, Voluntary Registers—Proposed Model for the Accreditation Scheme, the CHRE has stated that all voluntary registers seeking accreditation will be required to complete a risk assessment tool that will assess the risks inherent in a profession’s practice and the means by which those risks are and could be managed. The authority will also keep under review the management of risks by an accredited register. That will be part of its role.

However, having listened to the concerns raised in this House, the Government have given further consideration to this whole issue. Once a system of assured voluntary registration has been established for this group and has been operational for three years, to enable it to demonstrate its effectiveness the Government will commission a strategic review of the relative benefits of assured voluntary registration compared with statutory regulation. The review will involve all relevant professional bodies and trade unions. Such a review would include consideration of any further measures needed to assure the safety of patients and the public, including consideration of the case for compulsory statutory regulation or—and I say this in particular to the noble Lords, Lord Kakkar and Lord Hunt—making standards of training mandatory for employers through the use of standing rules for the NHS Commissioning Board and standard contracts for providers.

The noble Lord, Lord Kakkar, raised what I thought was a very astute point about the NHS standard contract. I can confirm that, yes, the Secretary of State will have the power to include in the standard contract the fact that relevant workers must be on a particular voluntary register. We see this as a strong lever, and we would want to consider it very carefully before deciding to use it in a particular instance, but wherever there was clear and demonstrable evidence that doing so would ensure quality of care, we would give it very serious consideration.

I can confirm that the question of whether to move to statutory regulation will be viewed openly, with full consideration of the potential benefits that it might be able to bring. I can say to my noble friend Lord Newton once again that the power to introduce statutory regulation already exists, in Section 60 of the Health Act, if a decision were to be made to deploy it. The Law Commission is in fact consulting at the moment on an even broader regulation-making power in the future. In the mean time, we are committed to exploring the evidence base on ratios of qualified to non-qualified staff. I totally agree with the noble Baroness that this is a key point. We will look carefully at the evidence from ongoing work by King’s College.

I have tried to set out what one might term, picking up a phrase from the noble Lord, Lord Patel, the direction of travel here. I hope that the noble Baroness, Lady Emerton, will understand our commitment to seeing defined standards and improved skills in the healthcare support workforce. The noble Baroness, Lady Masham, asked whether it is not time to have better safeguards in place. Yes, it is. I agree with her. Where we part company is on what a set of new safeguards should be. I strongly feel that a combination of voluntary registration and training is the more appropriate and proportionate solution to what I agree is a problem that needs to be addressed. The work that we have commissioned takes us on that road.

I hope that I have been able to reassure noble Lords of our commitment to strengthening the assurance processes in place for health and social care support workers, and that, perhaps with reservations but nevertheless more confidently than before, the noble Baroness—