Children and Families Bill
Lord Patel Excerpts(10 years, 6 months ago)
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Lord Patel
“Suitable education for children and young people
(1) Section 19 of the Education Act 1996 (exceptional provision of education in pupil referral units or elsewhere) is amended as follows.
(2) After subsection (5) insert—
“(5A) Suitable education for children and young people means—
(a) good quality education regardless of personal circumstance or education setting,(b) appropriate and tailored support to overcome barriers and meet a child or young person’s individual needs,(c) education suitable to the child or young person’s age, ability and to any social and emotional or special educational needs he or she may have, and(d) enabling children and young people to maintain academic progression and attainment, and allow them to thrive and prosper in the education system.”(3) Omit subsection (6).”
Lord Patel (CB)
My Lords, this amendment would add a new clause after Clause 23. It refers to Section 19 of the Education Act 1996 and seeks to improve it. Therefore, I hope that the Minister will find this a helpful amendment, as it seeks to do what he has been trying to do with his own amendments.
To summarise, Clause 19(6) of the Education Act 1996 would be repealed and after subsection (5) would be inserted a new subsection (5A), which refers to:
“Suitable education for children and young people”,
the definition of which would be inserted according to the wording of my amendment. The amendment would ensure that legislation and subsequent statutory guidance and regulations reflected the Government’s policy intention that all children, regardless of circumstance or setting, should receive a quality education as per the statutory guidance published in January 2013. I commend the Government for the publication of their guidance, and I shall come back to that again.
The reasoning behind my amendment is that Section 19(6) of the Education Act 1996 currently reads:
“In this section ‘suitable education’, in relation to a child or young person, means efficient education suitable to his age”—
it is always “his”, although it means “his or her”—
“ability … and to any special educational needs he may have”.
I consider that a more thorough definition of “suitable education” will help to achieve the Government’s aspiration for young children and persons learning in alternative provision, and it is that inclusion of alternative provision that I am seeking in the definition in the Education Act.
Alternative provision is defined as education arranged by local authorities for pupils who, because of exclusion, illness or other reasons, would not otherwise receive suitable education. This includes the education that a child or young person may receive in a hospital school, in a medical pupil referral unit or through home tuition.
The Committee may well be aware, since other noble Lords have referred to it, that CLIC Sargent, the UK’s leading cancer charity for children and young people, has found in a study that young people—particularly those with cancer, although it also applies to children with other diseases—who are receiving education in a hospital school or medical PRU setting while undergoing treatment do not receive a quality of education equal to those in mainstream education. Its research, published in the document No Child with Cancer Left Out, found that 70% of parents said that their child had very little education outside their normal school. In fact, to quote one parent of a child with cancer:
“We waited nearly a year for a home teacher who was brilliant, but it really should not have taken so long. Five hours a week home teaching is too little for a child in Year 6”.
Teenagers have also commented that the education they get is not appropriate for them at their age, or to help them get through exams. There is also a lack of funding from local authorities for home education.
I return to the Government’s intention, which I thoroughly support, and the statutory guidance for local authorities that they published earlier in the year. It clearly states that alternative provision and the framework surrounding it should offer good quality education on a par with that of mainstream schooling, along with the support that pupils need to overcome barriers to attainment. I agree that this support should meet a pupil’s individual needs, including social and emotional needs, and enable them to thrive and prosper in the education system. However, it is a statement of intention and good will, not a statement of a directive which the authorities may be obliged to follow. I hope that the Minister will see that strengthening the Education Act and defining suitable education more clearly may help.
I welcome the Government’s belief that,
“pupils with cancer deserve as good an education as any other pupil and poor health should never mean poor education”.—[Official Report, Commons, 10/1/13; col. 576.]
A key part of this will be to ensure that children and young people who receive alternative education receive a quality education, and that all education provision is responsive to the diverse range of needs of children with cancer and other serious conditions. I hope that the Minister will see that this amendment of mine helps his intention, so that he might either accept it or bring his own amendment at a later stage to strengthen the Education Act. I beg to move.
The Countess of Mar
My Lords, I shall speak to my amendments; there is rather a long list of them. They are Amendments 154, 160, 178, 185, 187, 189, 193, 197, 205C and 218. It seems an awfully long list but they are very simple amendments, which all say more or less the same thing. I declare my interest as chairman of Forward-ME, as patron of a number of ME charities and as vice-chair of the All-Party Group on ME.
I first became interested in virtual education in 2004, when the Young ME Sufferers Trust, or Tymes Trust, developed an alliance with Nisai Virtual Academy Ltd, also known as Nisai Learning. Together, they developed an educational programme for young people who were too ill to attend school or who could attend only intermittently and who, as a result, were missing out on large chunks of their education. At a function in the House last year the noble Lord, Lord Clement-Jones, founder-patron of the Tymes Trust, said:
“No wonder students with ME find concentration so difficult. When a student makes an effort, oxygen levels in the brain can fall instead of rising to cope with … demand. Obviously, it can be next to impossible to study effectively after struggling into school”.
He finished by saying that,
“students can be thought lazy, or just awkward when they are doing their best. Often staff do not realise why the student either can’t get to school at all or can’t concentrate on their work when they get there”.
Tymes Trust research has shown that,
“for young people with ME, the most effective form of education is home based, with interactive virtual education producing grades equivalent to, or higher than, other healthy students at school. The protocol that has been developed enables very sick students to achieve, when otherwise they are typically condemned to a recurring pattern of school attendance and subsequent relapse with little to show for it. They often feel that they are failures, when in reality it is the education system that has failed them”.
It is not just students with ME who benefit from virtual education, although ME is the biggest cause of long-term sick absence from school. There are young people with other medical illnesses who are not able to attend school, as my noble friend just said. Those with learning difficulties and emotional and behavioural disorders, those with disaffection with school or school-refusers, those who are excluded and sufferers from bullying, whom the noble Baroness, Lady Brinton, has so clearly defined, can all benefit from virtual education. Despite their myriad problems, those students, who would normally struggle to achieve any qualifications, find that a virtual environment is one in which they can flourish. This year, 91% of the students of Nisai Learning achieved GCSE and A-level qualifications, and 30.6% achieved A* to C grades. While this is below the national average, many of these students would have had no GCSE or A-levels under their belts.
The Bill focuses on provision for children with special educational needs who are in the main stream. That excludes some 100,000 children who do not have access to mainstream education, for some of the reasons that I have given. According to a BIS research paper published in January this year on the motivations and barriers to learning for NEETs—those not in employment, education or training—more than nine in 10 young people with experience of being a NEET are motivated to learn, while seven in 10 of the same young people looking for learning opportunities felt that there were barriers associated with access to education. It is intolerable that young people such as these should be left behind when we know that, with the right support at the right time, they can succeed.
Education outside the mainstream is often supplied by individual organisations that have created imaginative ways to help those who are excluded. However, the money assigned to a student while inside the mainstream system does not follow them once they are no longer on the school roll. That means that it is impossible for students to have access to alternative provision that would help them. The Bill gives us the opportunity to rectify that state.
Online and blended education mixes visual with auditory and verbal kinaesthetic modes of teaching, and ensures that children can focus on learning without the complications of external influences with which they may struggle. They are given a structure that supports them educationally and emotionally and which enables them to become economically independent. Online learning integrates a variety of learning styles, using teachers who have a comprehensive understanding of work processes and the special needs of students who have physical or emotional problems.
Students do not wake up one morning and decide that they do not want to learn any more; there are numerous factors that contribute to their lack of engagement. For children with ME with special educational needs, virtual education protects health and promotes recovery; results in better exam grades than a child with ME can otherwise achieve; costs less than home tuition; and can be accessed at any time of the day or night. The child remains on the school roll, and the school league table can include the child’s success. Very importantly, through virtual contact with other children in a similar position, children can make many new friends whom they are able to meet when they are well enough. As a sideline, I quote a note from a former head teacher:
“the purpose of education is to educate to the best standard possible; an attendance register is not a measure of achievement or success”.
The Countess of Mar
My Lords, I meant to do this in my initial speech: I thank the Minister and his department for the statutory guidance. Both the ME charities with which I work, which deal with young people, have been extremely grateful for it and are making good use of it. If we could get this embedded in the Bill or indeed into the system, that would be extremely helpful. I am grateful for his reassurances. I will read what he has said and think about it.
Lord Patel
My Lords, I thank the Minister for his comments, particularly the last ones that he made about working with the charitable organisations that work with children with cancers and other health conditions. My concern was not that he was not personally sincere about making sure that all these children got a good education, nor that the guidance already issued and the amendments that the Government have brought in do not go a long way towards making sure of that. My concern was that, while the intention is to ensure that all children get their education in mainstream education, which I agree is the best for them, there are times when these children cannot be in mainstream education because of their conditions. It is the gap that occurs—the provision that is not there to continue their education—that makes them fall behind when they re-enter mainstream education. It was in filling that gap that I was hoping to see whether I could be of some help through the amendments. However, I am reassured by what the Minister has said, and I hope that he and his team can work with those who are concerned to ensure that the guidance produces the required emphasis to make sure that this education for children continues in alternative provision. I beg leave to withdraw the amendment.
Health: Neglected Tropical Diseases
Lord Patel Excerpts(11 years, 3 months ago)
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Lord Patel
My Lords, I, too, thank the noble Baroness for initiating the debate and for other reasons which will become quite obvious in a minute. Much of the debate implies that we have treatments available for a lot of these diseases. That is far from the truth. We have some treatments available for some of the diseases, and none for others. In some cases, those that are available are highly toxic and, more likely than not, will kill the patient. We need more research in developing cheaper, more effective drugs. We also need a long-term strategy for the eradication of these diseases.
So far, we have succeeded in eradicating one disease: smallpox. We may succeed in eradicating guinea worm disease and possibly polio, but we are a long way from eradicating the others.
I am currently chancellor of the University of Dundee. I mention this because the University of Dundee has received funding from the Wellcome Trust in the fight against neglected parasitic diseases, including support for a multimillion-pound partnership with GlaxoSmithKline to discover new drug treatments. I have been associated with the University of Dundee since the day I went there as a medical student—I would hate to say how long ago that was. The Drug Discovery Unit at Dundee will work with the GSK discovery unit in Spain, and the goal of the collaboration is to develop safe and affordable treatments for Chagas disease, leishmaniasis and African sleeping sickness. The partnership aims to deliver at least one treatment for one of these diseases in the next five years.
These parasitic diseases afflict millions of people worldwide and are collectively responsible for about 150,000 deaths every year. The drugs that are available are difficult to administer, have toxic side-effects and are not always effective due to the drug-resistance of some of the parasites. We have made significant progress towards the development of a new treatment for African sleeping sickness over the past five years and there have been promising results in identifying potential treatments for leishmaniasis.
Currently we have a portfolio of discovery projects in various stages of development in African sleeping sickness and visceral leishmaniasis. We have several types of compounds with promising activity in animal models. The next step is chemically to modify these molecules to find the optimal balance of drug-like properties for clinical trials.
Having an industry-experienced, multidisciplinary drug discovery team is very important and this public/private partnership is critical in developing drugs for these neglected diseases. A report published by the London School of Economics and Political Science, called The New Landscape of Neglected Disease Drug Development, found on the basis of vast amount of empirical data that the PPP approach brings together the best skills of the public/private partnership, and that currently there is very little investment of public money for the development of drugs for neglected tropical diseases. The report points out a surprising lack of policy incentives to support PPPs, which have become a cornerstone of both large and small pharmaceutical companies’ involvement in neglected disease R&D, and adds that some of the incentives on offer could well be counterproductive.
It is important for the Minister to take on board that if we as a country are going to be successful in developing drugs for these diseases, there needs to be more support from public money so that we develop public/private partnerships.
Health: Neurological Services
Lord Patel Excerpts(11 years, 5 months ago)
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Lord Patel
My Lords, I am pleased to take part in this debate initiated by the noble Baroness, Lady Ford. She should be congratulated; I think that every patient with epilepsy would wish to congratulate her on her perseverance in ensuring that she holds the Government to account on services for patients with epilepsy.
As the noble Baroness, Lady Ford, mentioned, we had a similar debate more than two years ago, so the Minister is in a good position to have prepared her answers. The Question for Short Debate today is:
“To ask Her Majesty’s Government what progress has been made in improving neurological services, and in particular the provision of epilepsy services, in the United Kingdom”.
The last time we had this debate, the Minister ran out of time. It was late at night and she was unable to answer all the questions. I have adopted a different tack today: I shall put the same questions to her again. No doubt her assistants have read the Hansard of the debate then and they have had two years to try to address the issue of poor-quality care for patients with epilepsy. To remind her of what was said, I shall pose the same questions again.
To give some background, if the quality of services provided for people with epilepsy were measured on the basis of outcomes—that is, measured by appropriate diagnosis, appropriate and timely treatment, the education of patients and carers and avoidable deaths—the service currently provided would be regarded as a total failure. The Minister may contradict me by citing hard facts—not processes, because it is easy to say that progress is made by citing processes, such as that the Government have asked NICE to develop quality standards. That is good, but, as the noble Lord, Lord MacKenzie, said, quality standards will take some time to produce, be implemented and be audited, only to find that there has been no change. She may suggest that the mandate given to the commissioning board has within it a mandate to improve services related to neurological conditions but that, again, is a process.
I shall confine my comments to the care of children and young people with epilepsy. Epilepsy is the most common neurological condition among children and young people, affecting about one in every 200 of the population; that is, approximately 60,000 young people in total in the UK. On average, there is one child with severe epilepsy in every primary school and five in every secondary school.
Although those national numbers can be calculated, local and regional numbers are not available. If those numbers are not available, how are the commissioning groups to commission services for those children? Clinical guidelines from the National Institute for Health and Clinical Excellence exist, but they are not implemented in many areas. Where they are implemented, it is patchy. That means that children who have had seizures are typically referred to general paediatricians rather than paediatricians with training and expertise in epilepsy. From the very beginning, that makes the outcomes for those children poorer. Misdiagnosis is an issue. Up to 40% of children referred to a specialist clinic are not fully assessed as having epilepsy. If a child is branded as having epilepsy, they carry that diagnosis and treatment for life, so the outcome for those not fully assessed is worse than if they had been assessed as having epilepsy.
About 365 avoidable deaths occur per year of children with epilepsy. The Minister may correct me and tell me what progress has been made, because that is the number that I cited two years ago. If there is progress, that number should have come down—I know the real number, by the way. I look forward to hearing that.
I come to the five questions that I raised. They related to the campaign conducted by the National Centre for Young People with Epilepsy, which suggested 10 levers that could improve services for children with epilepsy—so two and a half years ago there was already help for the Government to have some idea of how to improve services. They were that NHS commissioners should know the number of children and young people with epilepsy in their area; the level of resources that they have in place to support these children and young people; the waiting times faced by children and young people with epilepsy for initial appointments, diagnosis, treatment and tertiary assessment; and the current perceptions of children, young people and their parents of epilepsy services. They also include the need for NHS commissioners to adopt one or more care pathways for children and young people with epilepsy; the need to ensure that they are seen by paediatricians with training and expertise in epilepsy; an easy-to-use and efficient process for referring children and young people to specialist epilepsy services; the need to ensure that every child or young person with epilepsy is offered a care plan; and the need for children or young adults with epilepsy to have their case reviewed at least once a year by a health professional with expertise and training in the epilepsies.
Those levers were based on National Institute for Health and Clinical Excellence guidelines and were therefore mandatory, so it ought to be easy to measure the progress against those indicators. I very much look forward to the Minister answering this time, because she will not run out of time today.
Family Planning: London Summit
Lord Patel Excerpts(11 years, 10 months ago)
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Lord Patel
What plans do the Government have to support the education of girls in this country for them better to understand the value of family planning?
Baroness Northover
The United Kingdom is committed to the support of family planning in the UK. There should be, and is, comprehensive access to contraceptive services and supplies across the UK. The noble Lord, Lord Patel, is quite right that education and information is important here as well as in developing countries.
EU: Healthcare
Lord Patel Excerpts(12 years, 4 months ago)
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Lord Patel
My Lords, I want to speak about the data protection directive. It regulates the processing of any personal information, and has been transposed in the UK as the Data Protection Act. That legislation covers any activities that involve data processing. They are as diverse as marketing and internet transactions, routine administrative data collection and the use of health records for research and clinical practice.
Health research is therefore only one small aspect of the directive, but that complex legislation has had a major impact on how health data are used in studies. Properly controlled access to individuals’ health records is essential for health research. Health records enable researchers to identify patients to take part in clinical trials and to provide data for observational studies, such as those looking for associations between particular lifestyle choices and ill health. Researchers find the legislative framework for the use of health data complex and confusing. For example, they are uncertain how much protection now offered by exemptions for research on how they handle anonymised data, where the identity of individuals is masked.
The European Commission will put forward a new legislative proposal to replace the data protection directive at the end of January. That is expected to increase the rights of individuals, and it is highly likely that that will have an impact on how we use health data in research, even if that is unintended.
The Government recognise the importance of the use of patient data in research. I welcome the recent commitment to consult on changes to the NHS Constitution to create a system that will enable patients’ records to be used in research unless they opt out. This is therefore an exciting but also anxious time for the use of health data in research. We must make sure that changes to EU data protection legislation do not inadvertently hamper those plans. I am sure that the noble Earl will liaise with the Justice Department to ensure that that is not the case.
Health and Social Care Bill
Lord Patel Excerpts(12 years, 4 months ago)
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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.
Lord Patel
I wish to pick up on one point. Can the noble Baroness reassure us on what it is she will keep under constant review? I understood her to say that the Government will rely on employers to ensure that these support workers have some kind of training. There will be no national training standards and, once the employers are satisfied that these people have some kind of training, they will be entitled to go on a voluntary register. As I understand it, the logical thing here is first to establish a national standard of training; then to ensure that those national standards are implemented; and then to allow people to register. If they register, the next step would be regulation. The first step is not immediate regulation but national standards of training and assessment that those standards are being met, before people can go through any kind of registration. What is the noble Baroness agreeing to keep under review?
Baroness Northover
I should perhaps explain that more precisely. This issue will be constantly under review so that if there are concerns in this area they will be flagged up. The Government will of course continually consider how best to respond and make sure that standards are of the quality that we need. The noble Lord is right: national standards of training are indeed the start. Then people are admitted to a register and so on. A voluntary-assured register would demand that kind of national level of standards in training. I hope that in that regard I can at least reassure the noble Lord.
Health and Social Care Bill
Lord Patel Excerpts(12 years, 5 months ago)
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Lord Patel
Lord Patel
My Lords, while the House settles down, I thought I might tell your Lordships what a hazardous journey I had here today. The temperature difference is only 12 degrees.
The amendments in this group relate mostly to issues concerning public health. It is to be commended that the Bill places a duty on the Secretary of State to take steps to protect the public from diseases and other dangers to health, putting public health at a high level of government responsibility and particularly that Public Health England, once established, will be accountable to the Secretary of State. I look forward to the public health outcomes framework. It is none the less disappointing that, while the Bill places a duty on the Secretary of State to pay regard to reducing inequalities in health, it does not do so for public health. None of my amendments will alter the thrust of the policy in the Bill; nor will they alter the structures for the delivery of public health locally or nationally. I hope that they will be seen as genuine attempts to improve the Bill and improve the chances of the delivery of the public health agenda. I am pleased that the amendments have such widespread support among noble Lords on all sides and I look forward to their contributions.
I will speak to Amendments 225, 226, 229 to 232, 233A, 234, 259 and 339. Amendment 225 deals with the appointment of directors of public health. Amendments 226, 229 and 231 allude to their training and qualifications. Amendment 228 applies to their accountability within the local authority and Amendment 230 concerns registration criteria. Amendment 234 applies to duties regarding the termination of employment of directors of public health and Amendment 259 concerns employment conditions. Amendment 339 deals with the regulation and registration of public health specialists.
As regards Amendments 228, 229, 230 and 231, the director of public health will be the strategic leader for public health in his or her local authority, providing expert public health advice and guidance across health protection, health improvement and health services. In order to provide effective strategic leadership, the director of public health must be able to influence all aspects of the work of the local authority in the wider determinants of health, such as housing, employment, access to services and education. He or she will also work with other organisations, including local health and well-being boards, HealthWatch England and clinical commissioning groups.
The director of public health must be an appropriately qualified and registered public health specialist. He or she must report directly to the accountable officer of the local authority, the chief executive. That is important because if the director of public health is not directly accountable to the chief executive but to some other person and, therefore, is subordinate, their authority will be diluted. The majority of directors of public health are now appointed jointly by the primary care trusts which employ them and local authorities to which they are seconded. Under the new system, all directors of public health will by law be jointly appointed by local authorities and the Secretary of State. That function will be undertaken by Public Health England and they will be located within and employed by local authorities.
As it currently stands, the Bill simply states that a local authority should “appoint an individual” without any specification of the required skills, expertise or stipulation of how these appointments should be carried out. A local authority could, for instance—indeed, there is some evidence that some are actively seeking to do so—tack the public health responsibilities onto, say, the duties of the director of adult social services or even the director of education. Most of them of course are wise and will not do that but it is possible.
Perhaps I may allude to some of the core competences that will be required of directors of public health, although this is not an exhaustive list. They will need to ensure the proper design, development, implementation and utilisation of the major information systems to underpin public health improvement and action for the population across disciplines and organisations. They will need to interpret and advise on highly complex epidemiological and statistical information about the health of populations to the local authority, the NHS and voluntary organisations, and to develop a strategy for reducing health inequalities. As executive directors, they will need to take a leadership role in specified areas with local communities and vulnerable hard-to-reach populations. They will have responsibility for dealing with infectious diseases and threats, including food and water-borne diseases. They will also have responsibility for preparing for emergencies, including pandemic influenza, and for safeguarding the health of the population in relation to communicable diseases, infection control and environmental health, including delivery of immunisation targets.
There are a lot of tasks and they are much more exhaustive than the list I have given the House. Therefore the person appointed as director of public health must have the appropriate qualifications and experience to carry out those tasks. The statutory requirement to have an appointments advisory committee that appoints directors of public health is therefore necessary. When appointing public health specialists, it provides a system which exists in the NHS now for all consultant appointments of monitoring applications for specialist public health posts. Through this system, candidates’ qualifications, training and experience are scrutinised by experts in the field of public health, usually the UK Faculty of Public Health advisers, to ensure that only appropriately qualified and trained people are appointed. Therefore it is important that all directors of public health and consultants in public health are appointed through a statutory appointments committee.
I turn to Amendment 234. Directors of public health will not only have many tasks, but they will have other accountabilities apart from the local authority. While their primary accountability is to the local authority, they will also be accountable to the director of Public Health England and have regional or national responsibilities in the wider public health service and for health protection. Yet while any authority that wishes to dismiss a director of public health will be obliged under statute to consult the Secretary of State, the Secretary of State will not have a veto over any dismissal, although he will be approving the appointment of a director of public health. I believe therefore that it is essential that any local authority wishing to terminate the appointment of its director of public health must be required in statute to have the Secretary of State’s approval and not merely to consult him or her.
In my view, the director of public health’s ability to report independently on the health needs of their community and population is important and critically on how well or not these needs are being met. He or she may be compromised if there is no protection against being sacked at the request of powerful local influences. The need for the Secretary of State’s approval is therefore necessary to reduce this risk. My amendment seeks to address this exceptional—I believe it will be exceptional—but nevertheless quite real possibility where the director of public health’s ability both to define and implement a local health strategy comes into conflict with other strong local interests seeking to dilute the impact of this strategy and compromise the health of the local population.
Amendment 259 will ensure that as public health specialists move out of existing NHS structures into Public Health England and local authorities, they will be guaranteed equivalent national terms and conditions of service to those in the NHS. That is important to ensure continued workforce capacity in public health, cohesiveness and skills and that public health remains an attractive career path. Clarity over the terms and conditions of employment for public health specialists would provide some measure of assurance that the profession will continue to be developed as an attractive one on a par with other medical specialties. The move of public health away from the NHS could potentially make it a less attractive career choice, particularly for young clinicians. That is an important factor. There is a real risk that without national terms and conditions, at parity with existing NHS terms, the public health workforce will become fragmented. As we saw in a report published last week, morale at the moment among the public health workforce is very low because of uncertainties about their role and the employment situation in the future.
Amendment 339 deals with regulation and registration of public health specialists and directors of public health. As Professor Scally concluded in his Review of the Regulation of Public Health Professionals, a review commissioned by the Chief Medical Officer of England and which investigated whether statutory regulation was needed for individuals operating at consultant level in public health,
“public expectation is such that, without the introduction of mandatory regulation of public health consultants and specialists by statutory health professional regulatory bodies, confidence would be lacking in public health professionals engaged at a high level in public health policy, planning and actions”.
Currently, we have a system whereby all medically qualified public health specialists working as consultants or directors of public health must by law be registered either with the General Medical Council or the General Dental Council if they are public health dentists. Specialists with a nursing or midwifery background are regulated through the Nursing and Midwifery Council. However, that is not the case with public health specialists from non-medical backgrounds, even though they will often carry identical responsibilities to their medically trained colleagues. A voluntary system of regulation, operated by the UK Public Health Register, is currently in place for those from backgrounds other than medicine. At the present time, in order to work at consultant or specialist level in public health in the NHS, a person must be on a specialist register such as that held by the GMC or the GDC. Non-medical specialists must be registered on the UK Public Health Register. With the move to local authorities of the majority of the public health workforce, the danger of a two-tier system of regulation or, worse still, no system of regulation could prevail. That is a risk.
Doctors trained as public health specialists have to undergo five years of training as specialist registrars and obtain a certificate of specialist training to be on the specialist register of the General Medical Council. Subsequently, they have to provide evidence of involvement in continuous professional development and be re-evaluated every five years. Similar mechanisms exist for dentists. The role of director of public health in a local authority carries a level of responsibility in relation to the health and well-being of the local population. It requires public confidence and credibility from other organisations. The person who holds such a post should be properly trained and qualified and be on a register. That would be appropriate.
The amendment would establish that all public health specialists not on medical or dental registers should be registered and that the Health Professions Council should establish such a register. I beg to move.
Lord Walton of Detchant
My Lords, I warmly support this clutch of amendments relating to the future of the public health service in the UK, so ably proposed by my noble friend Lord Patel. No doubt the Government have taken full account of the House of Commons Health Committee’s detailed report on public health, 12th Report of Session 2010-12, which raises a number of crucially important issues.
There are three principal domains of public health: health protection, which addresses environmental threats to population health; health improvement, tackling health inequalities and lifestyle issues impacting on health and well-being; and healthcare public health, which applies public health expertise to the provision of healthcare services. It is a significant omission in the Bill that it does not include any statutory duty on local authorities to address health inequalities in discharging their public health functions. That is a serious omission in the Government’s plans.
As my noble friend said, all directors of public health will by law be jointly appointed by local authorities and the Secretary of State, with the latter function being exercised through Public Health England, but they would be located within and employed by local authorities. Does this mean that directors of public health who hold medical and dental qualifications will, as at present, hold honorary consultant appointments, with all that that implies, as indeed my noble friend raised in his proposals? I agree entirely with his proposal that the appointment of such individuals should involve an advisory appointments committee accredited by the Faculty of Public Health, as is currently the case in respect of directors of public health within the NHS. Can the Minister confirm that that will be the case?
As my noble friend Lord Patel said, young doctors and dentists training for a career in public health undertake a programme of training for five years as specialist registrars. Who is going to employ them in the future? Will it be Public Health England? Local authorities do not understand what a registrar is, and for that reason it seems extremely difficult to consider that those people training for careers in public health will also fall under the ambit of the local authorities. Perhaps the Government can give us an assurance on that point. I agree with my noble friend Lord Patel that it is crucial that the director of public health be appointed at chief officer level, reporting directly to the council chief executive, and that any local authority wishing to terminate the appointment of its director of public health must be required by statute to have the Secretary of State’s approval.
Another important issue is to recognise the fact that healthcare public health, the third domain, is a core part of the public health service. Its role is to bring public health skills and knowledge to bear on the commissioning of health services, helping to ensure their quality, safety, efficacy, effectiveness, value for money and accessibility. The Government’s initial proposals were seen as downgrading the role of public health in the commissioning of healthcare services, but, happily, it has been clarified. The directors of public health and their teams will provide public health expertise, advice and analysis to commissioning groups, health and well-being boards, and the NHS Commissioning Board. This will be one of the mandated public health services that local authorities must commission or provide. However, this is not enough. Can the noble Earl give us an assurance that the local director of public health will be a member of the board of each clinical commissioning group? There should be a qualified public health professional on the NHS Commissioning Board; and the board should routinely take advice from qualified public health professionals when commissioning decisions are taken. We seek assurances from the Minister on that particular point.
Finally, I support very strongly the comments made by my noble friend Lord Patel about the regulation of public health specialists, including directors of public health who do not hold a medical or dental qualification. Those who are in possession of medical and dental qualifications are of course regulated by the General Medical Council and the General Dental Council. What about the specialists in public health who are not so qualified? Is it the Government’s intention, as Professor Gabriel Scally has indicated, that these individuals should come under the Health Professions Council for their registration? In my opinion and that of many professionals, some form of formal registration rather than voluntary registration is very important and, in fact, absolutely essential. I support these amendments.
Baroness Northover
I thank noble Lords for being so willing to receive letters about the areas that they are concerned about. I found myself retrieving what I learnt in my history degree, and I suppose this then becomes the Reformation. I will ensure that we write to noble Lords about these areas.
Lord Patel
I thank the Minister for her detailed answer. I know that this is a complicated group of amendments, each one referring to different aspects of public health. As I said in my opening remarks, it is extremely important that we realise that if we want a strong, reliable, effective, qualified, properly trained and accountable public health workforce, we need to address their accountability, employment status, registration and regulation. I did not put these amendments down lightly. They in no way seek to change the policy or structures of the Bill; they merely seek to strengthen the role of public health directors and public health consultants.
I do not know whether the noble Baroness passed the Warner test, but I listened carefully and I know she said a couple of times that the Government were looking at it and will produce a plan in early January. We will look at that carefully and carefully read what she said. I am very willing to engage with her because the public health faculty out there has great concerns. It is not concerned because it wants to be difficult; it is concerned that it will be asked to deliver something while its hands are tied behind its back. It would much rather come out into the open, to be told its status and to have that status put into the Bill so that it can begin to do the work that it is being asked to do. On that basis, I beg leave to withdraw the amendment.
Lord Patel
“( ) the exercise of the authority’s functions in relation to the control of any outbreak of disease or other public health emergency”
Lord Patel
In this group of amendments, Amendments 227 and 235 are particularly concerned with accountability in handling emergencies. It is essential that there is clarity about who, within the radius of local agencies involved, has the lead responsibility for managing the response in an emergency or an outbreak. I do not think the Bill makes that quite clear. There is a lot of ambiguity about it in the Bill, and my amendments merely seek clarification and to require it to be put into the Bill so that everybody is clear about who leads on it.
It is important to establish that at the local level this responsibility lies with the local authority and, on its behalf, with the director of public health. The director must have the experience, expertise and qualifications to make decisions about outbreaks and other health emergencies affecting the area. As we know, wrong decisions in the early stages of an outbreak—for example, failing to appreciate the seriousness of the situation, taking inadequate control measures or offering inappropriate advice—can quickly lead to a public health catastrophe. I will not go into the details of the E. coli outbreak, but it would be quite interesting to follow it. The Chinese pretty rapidly finally sequenced the E. coli that was affecting countries in Europe this summer, and that is a good case in point as to who takes the lead.
The Bill is unclear about the lines of responsibility or accountability for ensuring co-ordinated action. This lack of clarity about who is operationally responsible at the local level for ensuring that an effective response is put into place will result in delay and confusion. As the Bill currently stands, there is a great risk that emergencies, outbreaks and epidemic situations—for instance, the flu epidemic or recent outbreaks of E. coli— will not be properly managed or responded to and may quickly escalate and harm the health of the population.
The amendment makes it clear that the local authority will be required through regulations to ensure not only that plans are in place for responding to outbreaks or emergency situations but that an appropriate and effective response is made. Of course the local authority will not normally deliver the response itself; it will normally be provided by Public Health England, supported by the NHS and others in the local community, but the local authority will be responsible for ensuring that an effective, appropriate, integrated response is delivered. It will also then be able to hold Public Health England to account for the local services that it provides.
I inquired whether there had been any discussions between public health directors and Public Heath England about this, and I am encouraged that they met recently and that the relationship between the directors of public health and public health units—because Public Health England will have regional units—will be built on the fundamental assumption that the two arms of the public health system, the local authority through the director of public health and Public Health England, must work together and support each other to deliver an integrated service and to ensure that the population is effectively protected using all appropriate resources locally and nationally. Neither of them will duplicate the other’s functions.
There are four complementary principles that will define the working relationships. The local authority and the director on its behalf must be, and must be seen to be, responsible for the health of the local population. This will ensure that all aspects of public health are delivered in a locally coherent way. Under the Bill, the Secretary of State has a duty to protect the health of the population, which he or she will discharge through Public Health England. This will ensure a clear line of sight to the front line and the integration and consistency of health protection services across the country from national to local.
A principle of subsidiarity needs to be put in place, which is that the responsibility for health protection will be kept as close to local communities as possible. Public Health England will employ in local units the specialist expertise that it would not be cost-effective to replicate in every local authority. For instance, the Health Protection Agency currently has 25 units across England and national centres. The local authority through the director of public health will provide leadership for the public health system locally and must be responsible for ensuring that the system is prepared and delivers an effective health protection service.
I understand that more detailed work will define the range and scope of the core services that Public Health England will provide to the local authority. I know that we will come to a discussion about public health, and I do not wish to engage in discussion about Public Health England or my Amendment 260 at this stage. I merely refer to this in relation to the local authority’s responsibility for dealing with emergencies. I beg to move.
Baroness Emerton
I thank the Minister and look forward to seeing the regulations.
Lord Patel
My Lords, I thank noble Lords who took part in this debate. As I said in my opening remarks, the amendment seeks to clarify the responsibilities of the local authority in situations that arise as an emergency, either locally or nationally, and within that the role of the public health director. I realise that the Bill says that the Secretary of State, through Public Health England, will be involved, but there is still a lack of clarity in the Bill. Apart from saying that local authorities will produce documents about their preparedness to deal with an emergency, it does not say who will take charge. Further clarification may be required, and the Minister might undertake to look at the amendments again to see whether there is some need to clarify this in the Bill.
Baroness Williams of Crosby
I thank the Minister. I will spend many happy hours working my way through every possible legal complexity and a number of different Bills. I am grateful for her explanation.
Baroness Northover
My Lords, I will write to noble Lords if it is not that wide a definition, but my assumption is that it is the wider definition that needs to be covered.
As a brief response to the noble Lord, Lord Patel, I can say that much of this will be in regulations. I know that the previous Government had problems when they said that they would put something in regulations. The House would say that it wanted to know while it passed a Bill exactly what it would be, but a distinction needs to be drawn between the kind of things that you want in the Bill, where there needs to be an architecture and structure that gives flexibility, and the kind of precision and more detailed explanation that you have in regulations. The noble Lord will be familiar with that. If we can take anything further and outline what sort of things might be in the regulations, as the previous Government also sought to do, I am sure that we will.
Malawi
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Baroness Verma
The noble Baroness will know that I am not able to answer on each individual country at this moment in time, but I will get someone to write to her. The reductions are a result of our bilateral and multilateral reviews, where we saw that we needed to ensure that whatever moneys we were giving through aid via DfID were being well spent. The noble Baroness shakes her head, but she will know that during her time she faced the same sort of difficulties in ensuring that such programmes were both fully funded and fully scrutinised by the programmes we had in place. Governments needed to build up on good governance, which some were failing to do.
Lord Patel
I am sure that the Minister is well aware that Malawi has one of the highest maternal mortality ratios and one of the highest incidences of obstetric fistula. What impact assessment have the Government made of how programmes to deal with these will be affected by the redirection of aid?
Baroness Verma
I come back to my original Answer. I reassure the noble Lord that we have not cut back on aid but are redirecting the aid that was going through budget support to the health and education sectors, so we will be providing even more support by directing the aid to those sectors and having better oversight of where that money is being spent.
Open Public Services White Paper
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Baroness Verma
The noble Lord raises a number of interesting points. I did say that we are building on what the previous Government were doing. We are trying to make it a build-on that will be a bit more directed and focused on what the outcomes are going to be. I think that we are still in that mode of debating. It is important that we debate and discuss the best possible ways of delivering. These conversations do not stop just because a paper is produced. Consultation is an ongoing process, but it is also very important that we do not become so blinkered that we decide that the White Paper is not going to deliver anything. The White Paper is already able to deliver a lot, because we are building on what was already in place.
The structures will, of course, have areas that we will need to fine-tune and to look at how things can be made much tighter, but the Government are making sure that we have continuity plans and safety nets in place so that we can ensure that, when people make those choices, they are not left without support mechanisms. That is why we want to encourage champions to come forward through organisations such as Which? or HealthWatch and also make sure that there are ombudsmen for each sector, so that everyone knows that there is a line of recourse if they face difficulties.
Lord Patel
My Lords, on the face of it, allowing patients a choice as to where they wish their care to be delivered seems a good idea, except that there are several problems. One is the quality of information we have: if that choice is to be based on outcomes, it is pretty poor.
The second is that the outcome is not based on one treatment: it is the quality of the journey of care of a patient that delivers the best outcome. For instance, poor outcomes in cancer may well be, and are, related to late referrals of cancer patients. How does a patient know what quality of information they will be given that will allow them to make a choice as to how they wish their care to be provided, based on these outcomes?
Another issue is that the best quality might be far away from where the patient can go or have access to. So how would they make that choice? Most importantly, if we are going to do this—and the idea seems good—it should be based on what we have learned from pilots. Have there been any pilots done that will tell us how this will work?
Overseas Aid: Famine Relief
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Baroness Verma
The noble Lord is right. We have to work on a long-term plan, but we also have to react and respond to the crisis at the moment. The noble Lord will be aware that we have just had a review of the way we distribute humanitarian aid and we want to build on the recommendations of my noble friend Lord Ashdown so that there is resilience in the system as well as responding in the short term.
Lord Patel
My Lords, on the basis that famines do not occur overnight and that conditions exist for some time before the crisis develops, would it not be better if the Government were able to have some plans that they could put into action in order to be ahead of the curve, so that the effects of the famine, or other crisis, could be mitigated?
Baroness Verma
The noble Lord, Lord Patel, is right. Following on from the previous question, it is about ensuring that we have warning systems in place. We are also working hard to build long-term resilience by providing assistance on how to develop economic growth and by ensuring that populations are better educated in healthcare in order to be able to respond to the needs themselves.