Nursing

Lord Ribeiro Excerpts

Monday 14th May 2018 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, it is a real pleasure to follow the noble Baroness, Lady Cox, in this debate. She is a renowned globetrotter when it comes to humanitarian missions in Africa and other lower and middle-income countries. It was also a privilege to succeed her as president of my old school, Dean Close.

The noble Lord, Lord Crisp, to whom we owe this debate, in his book Turning the World Upside Down, referred to by the noble Baroness, Lady Bottomley, records meeting the founder of the Bangladesh Rural Action Committee in his headquarters within sight of the slums of Bangladesh. He asked him how the world could make faster progress in reducing death in childbirth. His reply was, “Empower the women”. That single statement is what this debate is all about, for a high proportion of nurses globally are still women.

A hundred years since women got the vote in the UK, they have scaled unimaginable heights, with many in the top echelons of the NHS, in management as chief executives of hospitals, in the Department of Health or as consultant nurses. That is not so in many lower and middle-income countries. Here, I declare an interest as a member of the All-Party Parliamentary Group on Global Health, which in 2016 took evidence on the future development of nursing globally. The most telling comment in our report was that nurses,

“are frequently not permitted to practise to the full extent of their competence; are unable to share their learning; and have too few opportunities to develop leadership, occupy leadership roles and influence wider policy”.

A commonly held term that has long been rejected in the UK was that, in not being able to utilise their skills, nurses were essentially “handmaidens” for doctors and had no scope for development. There are of course cultural and social barriers within developing countries which reinforce this stereotypical view, and it is time it was challenged. More must be done to empower women, who represent 90% of the nursing and midwifery workforce.

Another aspect of the Triple Impact report by the APPG on Global Health was the highlighting of workforce issues and the impact of migration. As noble Lords will know, I come from Ghana, which after 60 years of independence has faced many challenges in healthcare. I had worked there for a year in 1973, so can attest to the improvements nationally since that time. However, this evidence from Janet Kwansah on incentives for rural service among nurses in Ghana is worthy of note. She said:

“Like many countries in sub-Saharan Africa, Ghana is faced with the simultaneous challenges of increasing its health workforce, retaining them in country and promoting a rational distribution of staff in remote or deprived areas of the country. Recent increases in both public-sector doctor and nurse salaries have contributed to a decline in international out-migration, but problems of geographic mal-distribution remain”.


Brexit will have a significant impact on the UK, as Europe currently supplies the highest proportion of overseas nurses, at 29%. Brexit will see many European nurses leave, and the UK will have to resist the temptation to recruit nurses from lower and middle-income countries, as it has done in the past. The dilemma will be how to induce European nurses to stay, while avoiding the targeting of countries with nursing shortages. I ask my noble friend the Minister what strategies the Government have in mind to overcome this problem and the concern that I am sharing with the House.

Finally, I want to mention a new initiative funded by the National Institute for Health Research—the global surgery unit. I declare an interest as chairman of the independent advisory board of that group. Its purpose is to undertake surgical research to improve health outcomes in lower and middle-income countries through developing pathways for surgical innovation. The aim is to deliver sustainable changes in surgical practice in operating theatres in three continents, supported by a consortium of three UK universities: Birmingham, Edinburgh and Warwick. It will deliver the project through five overseas limbs in central America, west Africa, southern and eastern Africa, and south Asia, and will involve 40 lower and middle-income hospitals. We hope that this will not only have an impact on front-line surgeons but encourage nurses to participate, raising their profile and encouraging others to consider a career in nursing, as nurses are seen as part of the extended team and not merely as the handmaidens of doctors.

When I was president of the college and subsequently, I was privileged to undertake various visits to east Africa—to Ethiopia, Malawi and other countries—taking surgical teams to train local surgeons in surgical procedures. One thing we always did was take a nurse with us—Judy Mewburn. She was a great asset because, while we were teaching the doctors how to carry out surgical procedures, she would take the nurses aside and show them how to set up the trolleys in a sterile way. It is that collaborative approach of doctors and nurses working together that I believe will make a big difference. We see the benefits and effects of teamworking in the UK, with nurses being much more involved in the work of doctors. I hope we will be able to take some of those messages overseas and, by doing so, empower women to take up nursing and to provide the best possible care for their patients.

Health: Alma-Ata Declaration

Lord Ribeiro Excerpts

Monday 22nd January 2018 Lords Chamber

[Lord Bates]

The assessment of the level to which that is the case is a reflection of the priority which we give to primary care, as 90% of healthcare interventions are through primary care. It is absolutely right that we should have community-based solutions. I recently attended an event for the one-billionth treatment of neglected tropical diseases by Sight Savers. It was interesting to learn there that it had community dispensing people who went round in each community with a small measuring stick, which measured the dosage based on the height of the recipient. Two things were found: first, that it was very quick and efficient but, secondly, that there was greater acceptance and take-up because the people were from within the community and there was therefore greater trust. That is a model of how things ought to continue.

[Lord Ribeiro (Con)]

My Lords, following on from the question about the role of general practice, and mindful of the fact that we recently combined the Department of Health with social care, is it perhaps not time to redefine the role of general practice to ensure continuity of care between the two sectors and avoid some of the problems we saw in our A&E departments over the Christmas and new year period?

[Lord Bates]

That coming together of health services is obviously important. We share that knowledge and expertise through international health partnerships with some of the poorest countries in the world so that they can learn from it as well. But my noble friend is absolutely right to say that those first points of contact are essential in a good, functioning primary healthcare system, which was the Alma-Ata aspiration.

Children and Families Bill

Lord Ribeiro Excerpts

Monday 18th November 2013 Grand Committee

[Baroness Massey of Darwen]

My Lords, my name is on Amendment 263 and I shall be very brief indeed. We have just been discussing the Office of the Children’s Commissioner. We have just been talking about child protection. This also is a case of children’s rights. Children have the right to not be sitting in a smoke-filled car.

I was part of a debate on the Private Member’s Bill of the distinguished former surgeon, the noble Lord, Lord Ribeiro, who is here and will speak later on. He made a significant point. He said that awareness and behaviour change need to be coupled with legislation, and that smoking law at the moment does not cover cars.

The noble Lord, Lord Crisp, said that there are four questions to be asked. Is it dangerous? Yes. Are the dangers material and significant? Yes. Is it something that that affects other people? Yes. What are the downsides? They are modest. They are about having the freedom to smoke in a car when your children are present. It should not be allowed.

[Lord Ribeiro (Con)]

My Lords, I hear my name mentioned and I think I ought to say something very briefly. Your Lordships are influenced only by evidence. The evidence following the legislation in 2006 in Scotland and 2007 in England has already shown measurable effects in improving healthcare, particularly among non-smoking bar workers, in whom one study found an 89% reduction in cotinine concentration, which is a specific marker for tobacco smoke exposure.

That benefit should not be restricted to bar workers but should be the right of children who find themselves confined in cars where adults are smoking. I support this amendment very strongly. I hope that my noble friend the Minister will be minded to consider it. I realise that the Government have a programme for behavioural change and education and may wish to pursue that. The research, however, points to the fact that there is an improvement if we reduce second-hand smoke.

[Baroness Northover]

My words in front of me say that this may be a convenient moment for the Committee to adjourn. I know it is not. I am very grateful to noble Lords for abbreviating what they had to say. I am extremely grateful to our Hansard colleagues for staying on beyond their allotted time. I am sure that we will come back to this on Wednesday, but I am afraid that I will have to adjourn the Committee.

EU: Healthcare

Lord Ribeiro Excerpts

Wednesday 11th January 2012 Lords Chamber

[Lord Ribeiro]

My Lords, I apologise to the noble Lord, Lord Kakkar, for missing the beginning of his speech, and I thank him for bringing this debate to your Lordships’ House.

“The European working time directive is destroying surgical training”. This was a comment from a surgical trainee responding to the General Medical Council’s national training survey of 2010. It echoes warnings made by the Royal College of Surgeons since 2004, when the 58-hour maximum working week was introduced. In 2011, the Association of Surgeons in Training and the British Orthopaedic Trainees Association surveyed 1,887 trainees on the impact of the working time regulation, which introduced the 48-hour limit in 2009. Sixty-six per cent reported a deterioration in surgical training, only 1.6 per cent reported an improvement, and 67 per cent had to attend work when off duty to maintain their operative training and learning.

The GMC repeated that survey again in 2011. While showing an improvement in some specialties, it found no change in surgery, with 80 per cent of trainees working beyond their rostered hours. It found 60 per cent of trainees in obstetrics and gynaecology and surgery taking longer to achieve the required educational competences as a result of the working time regulation. In America, trainees are allowed to work up to a maximum of 80 hours, and in some specialties this can be increased to 88 hours.

I believe that a more flexible approach is needed to allow senior trainees on the verge of consultant practice to work longer hours if needed, as in the United States. A return to an average of 56 hours for craft specialties would allow new trainees, starting at 48 hours, the time to develop their skills as they progressed through their training to a maximum of 65 hours for senior trainees, as allowed by the opt-out clause of the EU and as noted by the noble Lord, Lord Crisp. A one-size-fits-all solution is not appropriate, and the feedback from trainees suggests that it is damaging their training. Will the Minister identify what steps the Government intend to take to ensure greater flexibility, and will the Government consider overturning the SiMAP and Jaeger judgments and revising the new deal and the WTR?

Health and Social Care Bill

Lord Ribeiro Excerpts

Monday 5th December 2011 Lords Chamber

[Baroness Emerton]

I apologise to the Minister; I was waiting to speak to my Amendment 236ZA. The issue of voluntary sector involvement is important because the changes proposed in the Bill have significant relevance to it and in particular to the voluntary aid societies. The British Red Cross and St John Ambulance provide emergency response and are recognised respondents under the regulations of the Civil Contingencies Act. I declare an interest as a member of St John Ambulance for 66 years.

The history of the status of these two organisations goes back to the Geneva Convention. Because they have a specific responsibility for providing emergency services, there needs to be clarity about the lines of accountability within local authorities. Both organisations are recognised in the humanitarian field and for first aid and for looking after civil or military emergency situations. That is their responsibility. The auxiliary status is enshrined both in the royal charter for the Red Cross and in the Geneva Convention. The Women's Royal Voluntary Service used to be included, but it has withdrawn from voluntary aid society status. Nevertheless, all voluntary organisations are important in that they are present and they will need to know how to be organised under these new arrangements. They want to be assured that they will be commissioned, as they are now under the Civil Contingencies Act. Prior to this Bill, they were commissioned by the PCTs through local authorities and these changes have significance for them in how they will be managed and how the chains of communication will work.

The community-based presence of both organisations means that they are involved in vital emergency responses. They are first-responders and deal with civil emergencies. They hold, for example, a large number of ambulances with four-wheel drive. Indeed, the London Ambulance Service says that it cannot possibly cope in an emergency without the backup of the volunteer ambulances, particularly in bad weather. I speak to this amendment because voluntary organisations need to be involved and need clarification of their communication with local authorities.

[Lord Ribeiro]

My Lords, I seek clarification because the noble Baroness, Lady Emerton, has just referred to a whole series of different emergencies. The noble Baroness, Lady Williams, referred earlier to Clause 43 and the question of emergencies. I am confused about what we mean by emergencies and, under the emergency powers, the relevant types of emergency that we are dealing with.

Clause 43 states that,

“‘a relevant emergency’, in relation to the Board or a clinical commissioning group, means any emergency which might affect the Board or the group”.

We then talk about the emergencies that might occur when there is a national disaster. I take noble Lords’ minds back to the bombings on 7/7 in 2005. That was a major national emergency that was managed by COBRA—an organisation that involves the Prime Minister, the Secretary of State and the Chief Medical Officer. All of them would be involved in that situation. We also referred to the E. coli epidemic earlier on and I take noble Lords back to the Asian flu and swine flu epidemics. The person who fronted that was not the Secretary of State but the Chief Medical Officer. He was the face of that particular epidemic. I think we need some clarification of what we mean by emergencies, because I, for one, am somewhat confused.

Health and Social Care Bill

Lord Ribeiro Excerpts

Wednesday 16th November 2011 Lords Chamber

[Lord Turnberg]

My Lords, I am also pleased that public health receives such a high profile in this Bill. I speak to Amendment 60B and one or two others in this group. There seem to be several aspects to the public health parts of this Bill being probed by these amendments. However there is one area of public health that might fall between too many bodies and where we might usefully explore how we can arrange for them to be better co-ordinated. The area is child and maternity services.

As I understand it, local authorities will be responsible for child public health services; the Commissioning Board for health visitors and immunisation services; and clinical commissioning groups for child health and maternity services. That will require all sorts of collaborations to be set up, and that is always a recipe for some problems. I hope that the noble Lord can give us an idea of how these sets of services can be rationalised in some way.

I shall now speak to Amendment 62 and some others. Clause 8 describes the Secretary of State’s duty to protect the public’s health. It details a number of specific responsibilities which, it so happens, are currently undertaken by the Health Protection Agency. I would like to comment on them. I have extolled the virtues of the HPA on a number of occasions, having observed it closely as the chairman of its predecessor, the PHLS, some years ago. Incidentally, the hero of the noble Baroness, Lady Cumberlege, is an employee of the Health Protection Agency. It is a remarkable organisation and the envy of the world. It jumps on outbreaks of infection very rapidly and has prevented many an epidemic. There are many examples of that.

I reiterate this because the HPA is to be swept up into a new arrangement, as we have heard, much more directly under the influence of the Secretary of State. Thank goodness it will not be within the Department of Health, but it will be very close to it. My fear is that we will weaken something of great value to the country. I have some specific questions for the noble Earl.

First, is it expected that all the current functions of the HPA will be taken on board, or are we to lose some? The list is pretty comprehensive but it may leave things out. If so, what would be lost and what would be preserved? Secondly, is it intended that all the staff will move across? They currently work as a very efficient and effective team—a lean, mean team—and any break-up will have an effect. Thirdly, is funding to be affected in the changeover? Will the new organisation have access to external research grant income? That is very important if it is to keep ahead of the infections, which keep changing every day. I have mentioned this before and the noble Earl has responded, but I should like him to respond again more forcefully on whether the organisation will have access to the Wellcome Trust grants, the Medical Research Council and others outside of the NIHR. One of the duties of the Secretary of State is to take steps that include,

“the conduct of research or such other steps as the Secretary of State considers appropriate”.

Finally, will the body have the degree of independence that will allow it to give advice to the Secretary of State unfettered by Civil Service restrictions?

I hope that the noble Earl can help us with these questions, because there is considerable unease in the HPA at the moment.

[Lord Ribeiro]

My Lords, I should like to speak very strongly in support of Amendment 65 in the name of the noble Lord, Lord Warner. Were the noble Lord, Lord Patel, here today, I am sure that he would also speak strongly in support of it because he raised the issue of patient records yesterday when we had a meeting with Professor Steve Field of the Future Forum. We were discussing information provision for patients and the use of computer records. He said that for many years when working in maternity he had given patients their own notes, and in all that time he could remember only two occasions on which the notes had gone missing. On one occasion, the patient reported that a dog had eaten the notes and, on the other, the notes were left on a bus and shredded, someone having recognised that they were important. Therefore, only two sets of notes were lost over a period of some 20 years. Patients are perfectly capable of looking after their own notes. When I was a surgeon in Ghana in 1974 it was certainly quite common for patients to come to the clinic with their notes, which often would otherwise have been lost.

The final message that came through was that we have spent billions of pounds on creating paperless records and computer records and are about to spend even more. The information that we were given yesterday at the Future Forum was that we should be looking at what can be done locally, bearing in mind that GPs have a computerised system of records. We heard another anecdote about an old lady who went to the out-patients’ clinic for her appointment and the consultant said, “I’m terribly sorry but we’ve lost your notes today”. She put her hand into her handbag and came out with a memory stick, saying, “Doctor, it’s all on here”.

I hope that the Minister will take note of Amendment 65 because I feel that it may well stimulate us to look again at patient records and the use of technology. We are, after all, in the 21st century and, although paper records are wonderful for us to have as a tactile instrument, they do not always contain the information that we need.