Nursing Quality and Compassion: The Future of Nursing Education

Lord Patel Excerpts

Tuesday 11th December 2012 Grand Committee

[Lord Patel]

My Lords, I realise that my time has been cut down; I was running the risk that I would be completely eliminated in a minute. However, I will try to cope with the three minutes that I now have.

First, I thank the noble Baroness for initiating this debate. I am sorry to hear that she is feeling unwell, but if she will kindly tell me what might be the best treatment, I will write a prescription. This is why I have always been used to taking advice from nurses first.

It is interesting that in this debate we have two nurses, two doctors, three former Health Ministers and a former teacher, who wrote the report on nursing education; and no doubt the current Minister will be the one to reply to it.

I had intended to concentrate on three issues: workforce planning, which the Willis report mentions; the education of nurses; and the registration of support workers. I will come to the last first.

I support what the noble Baroness, Lady Emerton, and the noble Lords, Lord Willis, and Lord MacKenzie, had to say. We have had this opportunity to discuss the large number of nursing support workers who are currently unemployed, and their training and registration. We will keep coming back to this until it is resolved. It is unacceptable that the Government still seem to think that employers should be responsible for whether these workers should be registered or not, and whether or not they should have training.

It is quite clear that the training of health workers who provide front-line healthcare should be mandatory. There should be a curriculum and an assessment, and they should then be registered. I understand that it is not possible to have a compulsory register straight away. However, we need to have a road map that will enable us to leave voluntary registration and move to proper registration.

I have no doubt that the Minister will not agree, but I am sure that we will keep coming back to this, and I look forward to a day when one of the political parties, when in government, will introduce registration. I hope that that will be the current Government.

I refer to two reports, both from the Royal College of Nursing. One, the Willis report, was commissioned by it, and the other was the Royal College of Nursing report, Overstretched. Under-resourced. The UK Nursing Labour Market Review 2012, which was published in October. Both of them highlighted the issue of what will happen to the workforce planning of nurses.

Experience in the 1990s showed that cutting student numbers led to a year on year reduction of new entrants, from 18,980 in 1990-91, to 12,000 in 1997-98. This contributed to an acknowledged nursing shortage later in the decade. The report highlights that there is a risk of repeating this funding and planning, for in 2011-12 there were approximately 22,640 places across the UK for nurse training, compared to 24,800 in 2010-11. Next year, there will be another 1,260 fewer places, with a total of around 23,000.

Workforce planning will be left at the local level, first of all with the local education and training boards, which will work with the commissioners to define how many training places there should be. Health Education England will then be charged with funding the numbers, and the national Commissioning Board will be responsible for providing oversight. The whole thing, therefore, will be left, with all due respect, to the managers, without any reference to the professionals who provide direct patient care.

In the report of the noble Lord, Lord Willis, the managers, NHS employers, felt that they,

“have confidence that through a co-operative and collaborative approach between service and education providers, the future workforce will not only continue to deliver quality care but will also be equipped to develop and deliver new and dynamic services for patients”.

I come back to my first point about support workers. The result of this will be more support workers, because costs will be cut, and there will be fewer graduate nurses. I declare an interest as the chancellor of the University of Dundee, where I have graduated several hundred nurses, the last occasion being on 14 November. I was also pleased to award several PhDs, so nursing is developing as an academic profession as well. I am therefore totally signed up to nurse graduates. I therefore plead with the Minister to look again at the training and registration of support workers.

Health: Mental Health

Lord Patel Excerpts

Wednesday 21st November 2012 Lords Chamber

[Earl Howe]

My Lords, my noble friend makes an important point, and I can reassure him on that. I know that he is concerned that IAPT services may be displacing other psychological therapies. In fact, having looked into this, I can tell him that data from the NHS finance mapping exercise shows that IAPT services are not displacing other therapies; I have figures here to prove that. Spending on non-IAPT psychological therapies has reduced very slightly, by just over 5%, but the overall picture is one of a dramatic expansion in the availability and range of psychological therapies.

[Lord Patel]

My Lords, as the mover of the amendment that put equality of mental and psychical health in legislation, I am pleased that the Government did not contest it again—albeit that it was won by a Division. I am also pleased that mental health is to be treated equally in the mandate.

[A noble Lord]

Question!

[Lord Patel]

I am coming to the question which is important. Having put it in the mandate, would it not now be right for the department to ask the Commissioning Board to produce a framework outcome for mental health so it can assess progress in treatment equality for mental health?

[Earl Howe]

My Lords, we expect the equal priority for mental and physical health to be reflected in all relevant aspects of the NHS’s work. There can be no single measure of parity. As I said earlier, we expect the board to be able to demonstrate measureable progress towards parity by 2015. However, there are some specific areas where we expect progress; for example, relevant measures from the NHS outcomes framework, including reducing excess mortality of people with severe mental illness; delivering the IAPT programme in full and extending it further; addressing unacceptable delays, and significantly improving access and waiting times; and working with others to support vulnerable and troubled families. Those are very detailed objectives for the board, all of which bear upon the key question of parity between mental and physical health.

Health: Cancer

Lord Patel Excerpts

Wednesday 7th November 2012 Lords Chamber

[Earl Howe]

I absolutely accept that one of the benefits we have seen from the clinical networks is the spread of innovative best practice through the health service, particularly in local areas. That is very much what we wish to preserve. The networks will help local commissioners of NHS care to reduce unwarranted variation in services and encourage innovation. We are determined to see that continue.

[Lord Patel]

As the Minister responsible for quality outcomes in healthcare, will the noble Earl report to the House on whether he is monitoring the effects on cancer outcomes of the reduction in the staffing of cancer networks?

[Earl Howe]

We will certainly be monitoring the outcomes in the field of cancer, but I would just like to impress upon the noble Lord that the creation of the clinical support teams—the network support teams—will ensure that the whole service is more efficiently delivered. By having 12 support teams there to underpin all the networks, we will ensure that we have a more cost-effective system.

NHS: Women Doctors

Lord Patel Excerpts

Tuesday 6th November 2012 Lords Chamber

[Earl Howe]

My Lords, the Government fully support flexible working. We encourage organisations to take account of the recommendation made by the noble Baroness, Lady Deech, on that subject and adopt working arrangements that are amenable both to doctors who are parents and doctors who are carers.

[Lord Patel]

My Lords, first, I declare an interest. In my family there are four women doctors—I do not call them “girls”. They are all higher achievers than I could ever be. Does the Minister agree that there are in some of the most demanding specialties more women doctors in higher positions than in some of the other specialties and that in the specialties where there are not, it is the attitude of the senior doctors—possibly even male doctors—that is the problem?

[Earl Howe]

I discussed this subject in my briefing with departmental officials. There are multiple and quite complex barriers to career progression, including a conflict of roles between someone’s clinical responsibilities and their domestic responsibilities. There are structural barriers, as I have mentioned, in relation to part-time work, and in terms of general practice there is the sessional GP contract, which is another barrier to progression. The lack of role models is a factor and we should not overlook individual and organisational mind-sets, to which the noble Lord alluded, which result in lower personal aspiration in this area.

Care Services: Elderly People

Lord Patel Excerpts

Wednesday 17th October 2012 Lords Chamber

[Earl Howe]

My Lords, it is the responsibility of the employing organisation to carry out appropriate checks on the people they intend to employ. They should take decisions in the context of their responsibility for the well-being of the people who use the service. That position has not changed, and indeed it must be at the core of the safeguarding agenda. Organisations need to risk-assess the suitability of their staff for the role, considering all the information they have on the person, including criminal record checks. If someone has a criminal conviction, the employer should consider how old and relevant that conviction is in the context of the activities that the person would be undertaking and the characteristics of the people they would be looking after. That situation cannot, I think, change substantively.

[Lord Patel]

My Lords, will the Minister follow up on the question asked by the noble Lord, Lord Hunt? What progress is his department making towards establishing skills requirements in the training and regulation of nurse support workers and care assistants?

[Earl Howe]

My Lords, we recognise that there is a need to drive up standards in this area. More care workers will be trained, including an ambition to double the number of care apprenticeships by 2017. We have commissioned Skills for Health and Skills for Care to develop, before the end of January next year, a code of conduct and minimum training standards for healthcare support workers and adult social care workers in England. We expect that these will cover minimum training or induction standards for a range of support tasks, including personal care and other activities. Through the Health and Social Care Act 2012 we are creating a system of external quality assurance for voluntary registers.

Care Homes

Lord Patel Excerpts

Wednesday 27th June 2012 Lords Chamber

[Earl Howe]

My Lords, it is true that CQC inspectors found that for the kind of services they inspected, there was more non-compliance in services run by the private sector. But the information the CQC gathered for its report does not enable it to analyse the reasons for that. I would simply say that all providers of services, whether in the independent sector or the NHS, need to ensure that they comply with essential standards. The noble Baroness summarised a number of the areas where the CQC found failings and I endorse her view that there is a fundamental failing across the system, not just in providers but in terms of commissioning as well. The examples of poor care show up a fundamental need for commissioners to review commissioning plans and care plans, and make sure not just that the providers are capable of offering and providing care to the right standards but that they are actually doing so at the right level for the patients and service users they look after.

[Lord Patel]

My Lords—

[The Chancellor of the Duchy of Lancaster (Lord Strathclyde)]

The noble Baroness, Lady Campbell, is trying to get in.

Health Research Authority (Amendment) Regulations 2012

Lord Patel Excerpts

Wednesday 13th June 2012 Grand Committee

[Lord Patel]

My Lords, my apologies to the Minister. I was not quick enough to get up. First, I welcome this order, which establishes the Health Research Authority. Like the noble Lords who have already spoken, I ask when we will have further legislation defining all the roles of the Health Research Authority. Can the noble Earl also confirm that this new authority will be required to give ethical approval to all research, no matter how it was funded? I am particularly keen to find out whether research that might be funded by individual trusts or, for that matter, by the department will also come under the ethical scrutiny of the Health Research Authority. Will the authority at this point be promoting research from the NHS, as the new NHS Act requires the foundation trusts and the commissioners to do?

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, I start by thanking the noble Lord, Lord Hunt of Kings Heath, for setting out so helpfully the intended roles for the Health Research Authority, which, I think by common consent, is a very positive move forward. It has got off to a solid start. I am grateful to him as well for giving us the opportunity to debate these instruments. They are the second of three steps in the establishment of the Health Research Authority. They amend instruments, laid last year, that established the Health Research Authority in December 2011 as a special health authority with an executive board. That was the first step in fulfilling the Government’s commitment in the March 2011 Plan for Growth to create a new body to streamline the approvals for health research, following an independent review of health research regulation and governance by the Academy of Medical Sciences.

The Health Research Authority was initially constituted with an executive-only board to allow it to begin work quickly on its important agenda. We were able to make suitable interim ex officio appointments from among the initial staff who transferred in.

The instruments that we are debating today provide for the Health Research Authority to have a chair and non-officer members as well, so that it has greater independence and credibility to perform its functions for the purpose of protecting and promoting the interests of patients and the public in health research. That is the second step.

Health and Social Care Act 2012

Lord Patel Excerpts

Wednesday 25th April 2012 Lords Chamber

[Earl Howe]

My Lords, it will be conducted by the Health Select Committee of another place. The process is that the Department of Health will submit a memorandum to the Health Select Committee and that memorandum will include a preliminary assessment of how the Act has worked out in practice relative to the objectives and benchmarks identified during the passage of the Bill.

[Lord Patel]

My Lords, the noble Earl said in response to the Question of the noble Baroness, Lady Deech, that in the interim period the department will be undertaking scrutiny of the work of the bodies set up. Can he tell the House how the results of that scrutiny will be reported to Parliament?

[Earl Howe]

My Lords, the performance of the health service will be very visible as we go along: we will have the NHS Commissioning Board producing its annual report; each clinical commissioning group will be publishing an annual report; directors of public health must produce an annual report; the Secretary of State has to report annually on the overall performance of the health service; and HealthWatch England has to publish an annual report. So there will be no shortage of transparency along the way.

Health: Pancreatic Cancer

Lord Patel Excerpts

Monday 23rd April 2012 Grand Committee

[Lord Patel]

My Lords, I want to report that the All-Party Parliamentary Group on Pancreatic Cancer is in the process of being set up, supported by Pancreatic Cancer UK. It now has the necessary qualifying members and will hold its first meeting soon. I hope that noble Lords present here will join it.

I had a speech prepared, but I have changed my mind because I can tell your Lordships the story of my noble friend Lord Turnberg, who is sitting on my left. He is reported to be a survivor of pancreatic cancer but he is not. His pancreatic cancer was diagnosed in 1997 and he was operated on. I have his permission to tell you this story, so I am not breaching any patient confidentiality. It subsequently turned out that it was acute pancreatitis, which his colleagues had diagnosed as pancreatic cancer. Although that was 1997, it highlights how difficult this disease is to diagnose. Nothing has changed and many noble Lords have commented on this. We need to improve our ability to diagnose pancreatic cancer. I also have personal stories of my own family: my mother and mother-in-law died of pancreatic cancer. Both faced their disease with courage. My mother was operated on and died a few days later. The surgeon was well meaning but did not have the competence to do the complicated surgery. I once watched my professorial colleague operate with a laparoscope for 18 hours. As the noble Lord, Lord Ribeiro, and the noble Lord, Lord Kakkar, have pointed out, it requires a great deal of stamina, courage and tenacity to do surgery for 18 hours through a laparoscope.

I was impressed by some aspects of Pancreatic Cancer UK’s survey. I would like to highlight three issues. Nearly 25 per cent of pancreatic patients experience symptoms for up to 12 months prior to diagnosis. That is a difficulty in diagnosis. Survival rates are poor but, as has been pointed out, there are, importantly, great variations in survival rates across cancer networks. This needs to be explained, because we need experienced people, particularly surgeons, to look after these patients. Comments have been made about biomarkers and it is true that biomarkers are a way of screening. However, we are a long way from achieving that. Research is being done in this country and in the United States to identify a biomarker and to identify genetic variations and genetic associations of at-risk patients. There is currently funding for research—at Cardiff University there is a programme grant for research on understanding the diagnosis and the variations in results.

The timing of the debate has gone wrong—the clock indicates that I have been speaking for only .07 minutes. That is good—I have time left. I was going to finish by pressing the Minister to look further at providing a full audit of pancreatic cancer services—along the lines of the Healthcare Quality Commission’s national bowel cancer audit—not just focusing on surgery but on all aspects of pancreatic cancers. Such an audit will also help better commissioning in the future and I hope the Minister will address it.

--- Later in debate ---

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, I thank the noble Lord, Lord Aberdare, for tabling today’s debate. I am aware that this is a very important issue for him and for countless other people and families across the country. The coalition Government’s cancer outcome strategy was published in January last year. It sets out how we will make sure that people with any form of cancer get care and outcomes as good as anywhere in the world, whoever they are and wherever in the country they live.

Probably the most important factor affecting the survival rates of any cancer is the speed with which it is diagnosed—I think all noble Lords mentioned that issue. We have addressed that in the cancer outcome strategy, and that is why we are supporting the strategy with more than £450 million over four years. This funding is part of more than £750 million of additional funding for cancer over the spending review period to support our ambitions for cancer care. On top of that, or course, a range of support is already available to help GPs assess when it is appropriate to refer patients for investigations for suspected cancer, such as a NICE referral guideline. However, we can do more to support them.

Cancer Research UK and the National Cancer Action Team are working together to develop a new GP engagement programme for the coming years that will allow them to increase awareness and improve training. This will all help diagnose cancer cases earlier. I can say to my noble friend Lord Selborne that Professor Willie Hamilton is currently developing a risk assessment tool to support GPs in the investigation of pancreatic cancer.

The noble Lord, Lord Aberdare, asked if the National Awareness and Early Diagnosis Initiative could do some specific work on pancreatic cancer. Our cancer outcome strategy says that we will work with a number of charities linked with rarer cancers. There have already been meetings with several, including Pancreatic Cancer UK and Pancreatic Cancer Action, to see what more might be done to diagnose these cancers earlier. The Government’s future work on pancreatic cancer will be informed by what we learn from those charities.

I am aware also that Pancreatic Cancer UK is hosting an early diagnosis workshop in June. The National Cancer Director, Professor Sir Mike Richards, my honourable friend the Minister of State for Care Services and officials from NAEDI will be attending. The workshop will be looking at practical steps that can be taken to help GPs and secondary care health professionals diagnose pancreatic cancer at the earliest stage possible. We look forward to receiving the findings of the workshop.

My noble friend Lord Sharkey and the noble Baroness, Lady Warwick, talked about the possibility of awareness campaigns. Decisions on campaign work in this financial year will be based on the evidence from the pilots that we have run regionally in 2011-12. To further address the need to improve awareness of rarer cancers such as pancreatic cancer, consideration is being given to piloting a symptom-based awareness campaign based on covering multiple cancers. We are talking with stakeholders, including rarer cancer charities, about that work.

Once pancreatic cancer is diagnosed, patients need to have access to appropriate and consistent treatment, delivered to a high standard, across the board. I am aware that there are variations in survival rates across the country and across cancer networks. Pancreatic Cancer UK’s Study for Survival 2011 confirmed that. Quite simply, it is not good enough and it must change. That is why we are providing data to help the National Health Service tackle regional variations. For example, the National Cancer Intelligence Network has made available data collections on survival rates and surgical resection rates across a range of cancers, including pancreatic cancer. These data will allow providers and commissioners to benchmark their services and outcomes against one another and to identify where improvements need to be made. They will then be able to channel resources into improving services in the areas that need to be brought up to an acceptable standard.

The noble Lord asked whether we would develop an audit of pancreatic service and care. The National Advisory Group on Clinical Audit and Enquiries recently considered a proposal for an audit of pancreatic cancer as part of the National Clinical Audit and Patient Outcomes Programme. I understand that the proposal was not recommended for inclusion in the national programme. However, the advisory group suggested that elements of the proposal could be taken forward as part of the existing bowel cancer audit when this is retendered in 2012. I will ensure that this option is considered when the department reviews the existing arrangements for the bowel cancer audit later this year.

In Improving Outcomes: A Strategy for Cancer—First Annual Report, published in December last year, we said that continuing to provide the NHS with benchmarked data,

“as a lever for improvements”,

is a priority for 2012.

Of course, a hugely important element in all this is the patient experience, to which the noble Baroness, Lady Warwick, referred. In December 2010, we published the report of the 2010 cancer patient experience survey, which recorded the views of more than 67,000 cancer patients across 158 trusts. The survey showed that 90 per cent of patients with an upper gastrointestinal cancer, which includes pancreatic cancer, reported having a clinical nurse specialist. The survey also showed that cancer patients who had support from a clinical nurse specialist had a better overall experience of care. We expect the National Health Service to consider this in developing its policies to improve patient experience. A 2011 survey is now in progress. We will be looking closely at the results of the survey to see where improvements have been made and where more needs to be done.

Research featured large in this debate, including in the speeches of the noble Lord, Lord Aberdare, my noble friends Lord St John of Bletso and Lord Sharkey, the noble Lord, Lord Kakkar, the noble Baroness, Lady Thornton, and others. The National Institute for Health Research is making a significant contribution to the search for scientific breakthroughs in pancreatic cancer. The institute’s clinical research network is currently hosting 17 studies of pancreatic cancer and is recruiting patients as we speak. In August 2011, the Government announced £6.5 million of funding for the Liverpool biomedical research unit for gastrointestinal disease. About half this investment will support pancreatic cancer research. The NIHR clinical research network, as mentioned by the noble Lord, Lord Kakkar, is currently hosting 17 trials and other well designed studies in pancreatic cancer that are recruiting patients. In 2010-11, a total of 687 patients were recruited to pancreatic cancer studies hosted by the CRN. The National Cancer Research Institute’s upper-gastrointestinal clinical studies group is dedicated to developing a portfolio of research studies in pancreatic cancer, and has a pancreatic cancer subgroup, which has developed a number of internationally run trials. That is a cause for some encouragement.

The noble Baroness, Lady Thornton, referred to the research involving processed meat. She is right; Swedish research published in the British Journal of Cancer in January 2012 said that two rashers of bacon or one sausage a day increases the risk of pancreatic cancer by 20 per cent. There is also a link with bowel cancer. The department urges everybody to have a balanced diet. As with other forms of cancer, higher consumption of fruit and vegetables seems to be protective, but I will write to the noble Baroness if I have any further information on that subject.

The noble Lord, Lord Aberdare, referred to new cancer drugs. Our priority is to ensure that cancer patients get the drugs that their doctors believe are best for them. We have delivered on our promise in the coalition agreement for a cancer drugs fund, with £650 million, all told, devoted to it. This funding has so far helped more than 12,500 cancer patients in England to access the cancer drugs that their clinicians recommend. We have listened to feedback on the first year of the fund’s operation, and today are publishing new guidance on the cancer drugs fund, which will further speed up access for patients. The new guidance makes it clear that patients will not normally need to go through the primary care trust funding processes prior to applying to the fund. In most cases, it will mean that patients are able to access drugs within a matter of days of an application being made to the fund. In the longer term, our intention is to introduce a system of value-based pricing for new drugs, with the aim of enabling patients to have greater access to effective and innovative new medicines. The whole premise of value-based pricing is to ensure that the price of a drug will be linked much more closely to its assessed value. It will bring the price that the NHS pays more into line with the value that a new medicine delivers.

My noble friend Lady Jolly asked about that. She also asked about mechanisms in the Health and Social Care Act that might assist cancer patients. The main mechanism is the outcomes framework, which will of course pervade everything that the NHS Commissioning Board does in the way of commissioning guidance, and will inform the way that the commissioning outcomes framework is developed. She also asked about engagement with the royal colleges. Ministers are currently meeting representatives from the royal colleges on education and training—I do not think on pancreatic cancer specifically but certainly on the training of doctors.

The noble Baroness, Lady Morgan, asked me a number of questions. The NHS outcomes framework— I pay tribute to the work of the All-Party Group on Cancer over a number of years—will be updated annually to ensure that the most appropriate measures are used for comprehensiveness, while recognising that we need to keep a broad continuity of indicators year on year. The refreshed NHS outcomes framework 2013-14 will be published alongside the mandate in the autumn. To support the ongoing development of the framework, we are in the process of establishing an independent technical advisory group that will provide advice to the department and the board about current indicators and proposals for new ones.

The noble Baroness asked about the national cancer patient experience survey. With the leave of the Committee, as there is a small amount of time left I propose to utilise it, unless there are any objections. In the first NHS outcomes framework we explained that the approach to Domain 4, which is patient experience, was evolutionary and the initial set of improvement areas for this domain was drawn from existing nationally co-ordinated surveys or from surveys that would be available in 2011-12. Collectively, the improvement areas aim to achieve wide coverage of the interactions that people have with the NHS and focus on different features of patient-centred care. Future work will involve refining surveys and developing new questions and measures to allow existing indicators to be replaced over time as necessary.

With regard to cancer networks, we have already made clear that there is a role for clinical networks such as cancer networks in the reformed NHS, as a place where clinicians from different sectors come together to improve the quality of care across integrated pathways, and the cancer networks are a clear example of how that way of working delivers better quality. That is why the Secretary of State announced last May that we would continue to fund cancer networks this year and that, subject to legislation, the Commissioning Board will support strengthened cancer networks.

The noble Lord, Lord St John of Bletso, asked about quality standards. There is no intention to produce a quality standard for pancreatic cancer as such, but in future there will continue to be flexibility in the library of quality standards to take account of new and emerging priorities, should such need arise.

Our ultimate goal is to improve survival rates and the quality of life for those living with all cancers, including pancreatic cancer. There are many challenges to be overcome but they are not insurmountable. Because of the Health and Social Act, clinical commissioning groups will be free to pursue innovative ways of delivering care that bring better results for all patients, including those with pancreatic cancer, and NHS provider organisations will have the operational independence to determine how best to meet the needs of commissioners.

We have set five ambitious but measureable goals: to prevent people from dying prematurely from cancer; to improve the quality of life for people with cancer; to help people recover from episodes of ill health; to improve the experience of care; and to ensure that all patients are treated and cared for in a safe environment. We will continue to deliver on those goals.

[Lord Patel]

I am not sure if it is in order for me to do this, but I know that whatever the Minister says is taken as gospel, and he quoted a study from Sweden about the association of eating meat with pancreatic cancer. I do not know about the quality of that study, but it sounds surprising that that amount of meat-eating increases the risk of pancreatic cancer by 20 per cent. I presume that he was talking about relative risk, not absolute risk.

[Earl Howe]

My Lords, I will be happy to clarify that point in a letter.

Health and Social Care Bill

Lord Patel Excerpts

Monday 19th March 2012 Lords Chamber

[Lord Turnberg]

My Lords, I rise to speak briefly, because much of what I might have said has already been said by the noble Baroness, Lady Cumberlege. I, too, am very grateful for the way that the noble Earl has listened to us and spoken and written to us with helpful comments, which I hope that he will reiterate today. I just want to make one point about the research undertaken by the current HPA. It is directed predominantly to infectious disease and bacterial and viral infections. In that area, it is really world-beating. Recently, two of its members of staff have been elected fellows of the Academy of Medical Sciences, which is quite an achievement. The idea that it should do all this research in academic research partnerships with universities is unhelpful. Although collaboration and co-operation with university departments is enormously valuable, it should not be a precondition that it should be able to do research only in collaboration with universities. I hope that the noble Earl will be able to nail that problem.

[Lord Patel]

My Lords, I shall speak very briefly. I spoke at length in Committee and on Report and I shall not repeat what I said. Other noble Lords have referred to the key issues. If Public Health England is to be a strong, high-profile, public health national organisation, it needs strong governance. It also needs the independent ability to bid for research funds, as the HPA currently does, as has been highlighted, both nationally and internationally. At the Report stage, I referred to the fact that the HPA currently gets a significant amount of contract research income from NIH. It is no easy task to get money from NIH for research. If it is forbidden to do that, and, as the noble Lord, Lord Turnberg, said, is allowed to do research only with academic institutions, and not independently, that will be wrong. I hope that the noble Earl, who has listened to the arguments in the meetings we have had, will be able to alleviate those anxieties.

[Lord Beecham]

My Lords, I join other noble Lords in congratulating the noble Baroness, Lady Cumberlege, on the enormous effort that she has put in to moving the Government’s position somewhat although, as she says, in the view of some of us, not quite far enough.

The noble Baroness, Lady Jolly, referred to a degree of separation. I would rather that we had six degrees of separation; I think that we will probably have to settle for the current single degree of separation. That is slightly unfortunate, because, as other noble Lords have stressed, the question of independence of the organisation is crucial. In moving the amendment, the noble Baroness, Lady Cumberlege, raised that issue and mentioned the Civil Service code and the possible inhibitions on employees of Public Health England and what was the Health Protection Agency in giving that advice independently and openly.

Bearing in mind the discussions that we had earlier this afternoon about the relationship between civil servants and Ministers, I hope that the noble Earl will address that, if not today in his reply then subsequently, to explain how that relationship will work and to confirm the complete independence of members of staff in advising not only Ministers but, as the noble Baroness said, the public. I reinforce the points made by other noble Lords. I think we got a verbal assurance from the Minister last time, but I would like it fully explained that the research capacity of the organisation will be maintained.

The amendment is slightly more modest than originally proposed by the noble Baroness, and even more modest than some of us would have liked. For the life of me, I cannot see why the noble Earl should not be able to accept it. If he is not prepared to do that, perhaps he will explain why. At the very least, I hope that he gives the assurances and undertakings that the noble Baroness has sought and that we can take forward this part of the Bill, which in turn complements the best part of the Bill, which relates to public health in general.

--- Later in debate ---

[Baroness Emerton]

My Lords, the amendment concerns the power to register healthcare support workers in England. I shall try to be brief, as we had a long and thorough debate on this matter on Report and I have studied the Minister’s response to my amendment at that stage. I have had protracted discussions between Report and now with the noble Earl and officials, and I thank them most sincerely for the time and effort they have put into trying to meet my requests.

Healthcare support workers form a very large part of the workforce, whether they are in the employment of NHS hospitals, community services or local authority services, providing care in people’s homes, or in the large number of nursing and residential care homes. We should not forget the role played by social workers, which often overlaps with the role of healthcare support workers, and vice versa.

Many noble Lords have said in previous debates that large numbers of support workers provide high-quality care, and they have received some training in order to do that. It is not likely that this large number of support workers will decrease with a growth in demand from the rapidly expanding number of elderly, frail and vulnerable people who require high-quality care. However, it is also not possible to expect a magic wand—that is, the Government—to provide training overnight for everybody at once. Therefore, it is reasonable to find a way forward that provides a direction of travel that satisfies patients, the public, the professions and employers that the issue is being addressed as a matter of urgency within the economic situation in which we find ourselves.

I shall briefly address each item covered by the amendment. The Minister has indicated that Skills for Care and Skills for Health will be producing an assured training programme, prepared with professional inputs, that will, following consultation, be available for implementation in 2013. This will entitle successful candidates to be entered on the voluntary register if they so wish.

I am aware, and pleased, that the Minister has also agreed that work should proceed on reviewing the research on ratios of registered to unregistered personnel, and that the supervision of work delegated to registrants is vital. However, realistically, in some communities and hospital situations it is not possible for there to be close scrutiny of support workers’ performance. The recent report published by Which? clearly demonstrates neglect in the delivery of care to patients and in their safety. Clearly, the Government need a means of early identification of the failings in the delivery of care.

While the training programmes are being developed, perhaps we could ask, through the Minister, that registered nurses and midwives are reminded of their responsibility and accountability, that they have to assure themselves of the competences of individual support workers before delegating a task, and that, once a task has been delegated, it must be supervised. Where that proves impossible because of insufficient registered nurses and midwives, immediate action should be taken by a registered nurse to report to his or her manager and the employers should take action on the level of care that can be delivered in that situation. That will safeguard the safety and quality of care to patients.

I now turn to the second subsection of the proposed new clause. It is recommended that the next logical step would be to aim for the training of support workers to be mandatory. So far discussions on making the training of healthcare support workers mandatory has not found favour with Her Majesty’s Government. Many Peers indicated, on Report, the importance of all healthcare support workers receiving mandatory training and that it should be regulated. Although it is recognised that that could not be arrived at tomorrow, if Her Majesty’s Government could agree that the training programmes will be mandatory at a date to be determined for implementation, I am sure that the patients, the public and certainly the professions of nursing, midwifery and social care would be satisfied.

Subsection (3) of the proposed new clause requires the Secretary of State to develop a code of conduct for all employees whether they are entered on the register or just providing care. That includes the employees not just in the NHS hospitals but also in local authorities. That would provide clear guidance for employers as well as employees and should assist in ensuring that competences, where lacking, are made good by training modules or by withdrawing the person who does not have the skills or the competences. Without such controls of clearly defined competences being included for practising healthcare support workers and the correct delegation and supervision by registrants, it will be impossible to ensure the high-quality, safe, compassionate care that patients and clients deserve or indeed Her Majesty’s Government aim to provide. I hope that the Minister will feel able to provide a positive response to this request.

Subsection (4) requires Her Majesty’s Government to carry out a strategic review within three years, as the Minister undertook to do on Report, about whether statutory regulation of support workers is necessary in the light of progress with the proposed training programmes and the introduction of the voluntary register. Perhaps I may suggest that the review of the research on improving the ratios of registered nurses and midwives is also included in this review so that a holistic view can be gained of the future shape of the workforce required to deliver high-quality, safe and compassionate care, with the result of improved clinical outcomes that are cost-effective and of cost benefit. I beg to move.

[Lord Patel]

My Lords, on Report, I spoke strongly in support of the amendment in the name of my noble friend Lady Emerton. I thank the Minister for the many conversations that he has had with my noble friend and myself to try to resolve some of the issues. Like the noble Baroness, I am most appreciative of his readiness to meet and speak with us on many occasions.

We have about 450,000 healthcare support workers and some have had some training and therefore perform the tasks that they are given with fairly good competency. Others do not have any training and they might perform the tasks that they are given at variable levels. We also heard on Report from the noble Lord, Lord MacKenzie, and my noble friend Lady Emerton about the kind of tasks that healthcare support workers currently carry out. They range from simple nursing care or bathing or feeding duties to cannulisation and bladder catheterisation and even more invasive procedures than that. That should confirm to us that there is a need for some kind of standardised training programme that healthcare support workers must undertake so that their competences are assessed and so that they work to those competences. It is not fair that those healthcare support workers who have had some training and are competent to perform their duties have to work alongside others who have not had any training and, therefore, are lacking in competences.

On Report, one of the many things that the Minister agreed to take forward in relation to healthcare support workers, if I quote him correctly, was to try to establish assured voluntary registration, which the Council for Healthcare Regulatory Excellence will run. If we are to have any kind of register, surely ipso facto certain conditions must be satisfied before someone can go on to the register. Logically, that would suggest to me that there must be some form of training. If that is the case, why would we object to having training as a requirement for all new healthcare support workers? I well understand that it is not impossible, but very difficult and expensive, to try to train some 450,000 people who already carry out such tasks. That could be overcome by having a code of conduct imposed on employers; it would be their duty to ensure that whoever they employ has the competencies to do the tasks that they are asked to undertake. It would not be vastly expensive to get 450,000 people trained. Subsection (2) of the proposed new clause refers to “mandatory” training—I use the word “requirement”—for all new healthcare support workers from April 2003 before they go on the assured voluntary register.

I take a slightly different view about whether the register is voluntary or statutory. I know that the word “statutory” to all healthcare workers is important. I am registered by statute to be on the medical register but it is more important that the register has some meaning and that it works. If a voluntary register does not work, it is no good; if a statutory register does not work, it is no good. It is important that people who go on the register are trained and assessed as having those competences. Subsection (4) of the proposed new clause, to which the Minister agreed previously, requires that a review will be carried out for the benefit or otherwise of any kind of register that is established. I hope he will agree to that. I hope that the Minister will be able today to reassure my noble friend Lady Emerton.

I have been very touched by what my noble friend has said in the many conversations that she has had with me. To me, she typifies the attitude of a very caring nurse who is concerned about the poor quality of care seen in daily reports in newspapers; there was also a report yesterday from Which?, to which she alluded. That clearly affects her as a professional nurse. Therefore, I strongly support her amendment.