Health and Social Care Bill

Lord Rooker Excerpts

Wednesday 9th November 2011 Lords Chamber

[Baroness Murphy]

My Lords, by now it will be no surprise to the Opposition that I do not support this amendment. It seems to be an extraordinary pedalling-backwards amendment. I ought to remind colleagues that foundation trusts already have the ability to negotiate local terms and conditions of service, so at least two-thirds of mental health trusts and half of all acute trusts already have it. They have not used those freedoms for very sound reasons, but there will come a time when gradually they will want to do so. It seems extraordinary that we would seek to remove those freedoms. I say to those who are anxious about pushing pay downwards that that has not happened at all with consultant grades of pay, where freedoms have led to much greater flexibility and a real and genuine recognition of the rarity of some consultant specialties in some areas, so it is not a good idea to remove that pay bargaining and that flexibility locally.

I do not see the Agenda for Change as being successful. Yes, it was better than the Whitley Council, which had 250 different scales and you did not know where you were; it was pretty grim. However, Agenda for Change has not been implemented with the learning and skills framework alongside in any more than 50 per cent of trusts. It has not led to productivity gains. It led to an uplift of pay but did not actually deliver what employers wanted it to deliver.

In my view, a good employment framework for local organisations must take account of local economic circumstances, the social demographic mix and the skills available in the local communities. Therefore, it must give local employers greater flexibility, as part of the autonomy of those organisations, and the ability to move away gradually from the situation that we have at the moment of profound skill shortages of nurses in some areas and an oversupply of some skills in other areas. If we could be more sensitive to local circumstances, we would get better values and rewards for staff in the NHS. I therefore very much support the Government’s approach to this and do not support this amendment.

[Lord Rooker]

My Lords, I intervene briefly in this debate. It also gives me the opportunity to apologise to the House. I removed Amendments 35 and 36 at 10 pm on Monday because I could not guarantee to be here at 3.30 pm today. I apologise if it caused confusion, but I could not be here today at that time.

On Amendment 45, I would like to know the Government’s position, because the noble Baroness said that the Government maintain their position. In some ways, the temptation for fragmentation is enormous. I am not sure whether the NHS is still the largest employer in Europe. As a totality, I think it probably is. However, we are talking here about England—or are we? The issue of devolution is crucial. I served for 12 months as a direct rule Minister in Northern Ireland, and I came across problems there relating to people doing the same job here. Also, of course, moving around Whitehall, as the Minister probably discovered himself, you go into departments and meet people doing more or less exactly the same job on vastly different salaries. The temptation of fragmentation was accepted at the centre of government, and that has led to significant problems of mobility for people moving even around Whitehall.

I am no expert on the NHS—I only know it as a patient and a family member of patients—but as far as I am concerned, it is a team effort. It is a bit like the argument we had with the firefighters. You are sending people out on a team to do a job, and they are not going out on different rates of pay, different pensions and different contracts. The one way to keep it cohesive is to maintain national pay bargaining. It does not mean that one size fits all, but the fact is, as my noble friend who kicked this off said, the industrial relations implications are enormous, given the potential for disputes that nobody wants. A dispute is created because of a festering sore on something else. The facility is not there if you have a system of national pay bargaining for healthcare staff.

The amendment refers to,

“services for the improvement of public health”.

Quite clearly, there will be transfers of public health staff who are working in local government and who are perhaps working to and with NHS rates of pay. That in itself will be a difficulty if people are going to work with colleagues in local government under a different scheme. While the Government take account of that, the temptation will be to level down to local government to get one size fits all at the local level. I do not think that that temptation ought to be accepted.

As for the issue of regional break-up, there was an argument about this many years ago when there was an attempt to pay teachers more who were prepared to go and work in the inner cities. You can have a local premium, and you can do some local work where there are factors, but in the case of nursing staff, particularly the lower-paid, and their ability to move around the country for career opportunities and to move their family, they are working within one service. Everybody knows that it is the NHS—the “N” is still there—but they are faced with the issue that, for the same job in the next region or the next but one region, they may be paid up to 10 per cent less and their pension and terms and conditions may be different. That could cause enormous problems.

I only spoke in the mental health debate last week, but the overall theme of the Bill and the many allegations that have been sent to noble Lords, of which the Minister will be aware, are that this is a grand plan—not now, but in the end—to fragment and break up the National Health Service, a plot hatched in the 1980s by Members of the other House who are currently members of the Government. The introduction of market forces into both the provision of care and other providers, and the temptation then to break up national pay bargaining to fit the new regime, which is supposed to be patient-oriented, is an enormous pressure on the Government. Ministers will be told that this will make sense at the local level. It may be asking a lot for the Minister to give a definitive response to this tonight, but the issues of industrial relations and pay bargaining in the NHS have to be settled well before the passage of this Bill, if only because during the period of implementation we do not, as my noble friend said, want discord among the staff as they implement what will be, I accept, many positive changes in the Bill.

The other issue that has to be raised, because we are talking about services to patients, is the pay and bargaining within service providers as the issue gets broken up. There will be some debates about charities, the third sector and social enterprise involvement where industrial relations and pay bargaining may be affected. However, there are other issues relating to the private sector doing jobs using NHS staff. It offers mobility as teams move. People do not have one place of work but may move between two or three different establishments, one of which may be the NHS, in which they may be based. They are expected to perform as part of the team locally, providing the services to patients in the round. What happens to pay bargaining in those situations?

If we allow fragmentation at a local level, it would be wise for the Minister to say that the status quo will be maintained. I accept that the status quo has flexibility built in, as the noble Baroness said, but it is a flexibility that does not appear to have been used. This is a bit like the Scottish Government. They had the flexibility to put up income tax by 5 per cent, but it has never been done. This is the reality. You put in that flexibility but for various reasons there are barriers to actually using it. In this case, the evidence is that the flexibility has not been used except perhaps in extreme circumstances. I do not think that it would be a good idea if we went down this route. I think there is enough evidence to keep people working together as a team with a national perspective that allows job mobility and promotion without people being afraid of moving within the same service because of the pay and conditions. I do not think that it is a good idea, and I hope the Minister will be able to take a more positive approach to this issue, even if he can only state it in general terms.

[Earl Howe]

My Lords, Amendment 45, tabled by the noble Baroness, Lady Wheeler, seeks to impose on the Secretary of State,

“a duty to maintain a national pay and bargaining system for healthcare staff, to cover those staff providing”,

both NHS and public health services. This would cover not only existing NHS organisations but any organisation providing services to the NHS. The amendment, as worded, goes against the Government’s view that employers are best placed to determine the most appropriate pay and reward package to ensure that they recruit and retain the workforce that they need.

Our clear view is that it would be inappropriate to require independent and voluntary sector providers to adhere to NHS pay when NHS foundation trusts, as the noble Baroness, Lady Murphy, rightly pointed out, already have such freedoms. The Government believe that to deliver the best care for patients, this freedom should be extended to all NHS organisations. I also take the noble Baroness’s point that while foundation trusts have the power to apply local terms and conditions for all staff, medical, clinical and administrative, very few trusts exercise those freedoms. There are around 400 trusts, and only one foundation trust—Southend—has departed from Agenda for Change, and the differences that it has negotiated are marginal.

--- Later in debate ---

[Lord Rooker]

For the public health directors, who will be the employer? Will it be the local authority? In the sense that you can pay a director of education or children’s services market rates around local government, will that be the same for the directors of public health, so that their salaries vary around the country? It would be the beginnings of a new service, in that sense. Do we know the answer to that?

[Earl Howe]

They will be employed by local authorities. It is too soon to say to the noble Lord what the pay grade of those people will be, but clearly they will be very senior officers within the local authority. Yes, strictly speaking, if there is freedom to set pay locally, there could be some variations around the country, but I would envisage that the pay grade of directors of public health will gravitate towards a certain figure, whatever that may be.

Health and Social Care Bill

Lord Rooker Excerpts

Wednesday 2nd November 2011 Lords Chamber

[The Archbishop of York]

My Lords, I speak as somebody who supports Mind and as somebody with a brother I followed who had acute mental illness and died from it two years ago. I have listened to noble Lords’ speeches, and that of the noble Baroness who moved the amendment, on this amendment and the consequential Amendments 105 and 180. I agree with everything that they have said. It is important to highlight the fact that health and illness include both mental and physical aspects; to me that is not problematic. However, the question I want to ask is, do we still need to speak of them in almost separate categories? The noble Baroness, Lady Murphy, referred to my anxiety; namely, that because we have separated out mental and physical illness, would inserting the words “physical and mental” in relation to illness continue to exacerbate the problem? Is it necessary to put “physical and mental” in this part of the Bill, or will the noble Earl tell us where that matter can be spelt out elsewhere, not necessarily in the Bill?

Noble Lords will probably say of my next point, “We would expect him to say that”. I am one of those who believe that human beings are psychosomatic spiritual entities. The element of the spiritual well-being of people is not on the face of the Bill but I am absolutely convinced that, as it stands, my needs would be taken care of because it talks about,

“the prevention, diagnosis or treatment of illness”.

Illness can be physical or mental but it can also be spiritual. I will not detain noble Lords long but when I first became a vicar of a parish in south London I was invited into a home because somebody said that there was a presence there. I did not understand that phrase but I went into the home where there was a young girl who had not been able to move for nearly three weeks. The GP, a psychiatrist and a psychologist had visited the house. Sometimes the girl shouted a lot in the middle of the night. I went into the house and asked how the girl had got into that difficult state. Somebody said that they had been to a witches’ coven that night where a goat had been sacrificed and the young girl was absolutely petrified that she would be sacrificed next. She could not speak apart from shouting. Doctors, psychiatrists and psychologists had attended the girl. All that I could do was to say a prayer in that little house, anoint the girl with oil and light a candle. I left and received a telephone call later to say that the young girl was no longer terrified and had started to speak. That was not mental or physical illness; there was something in her spirit that needed to be set free.

I am content that the Bill covers all those aspects of the human person simply by using the word “illness” and through establishing a well-being and health board, which suggests to me that that board has a responsibility to ensure that physical, mental and spiritual well-being are taken care of. After all, in our schools these days we emphasise not only the personal, but the physical, mental and spiritual dimensions of a person. Hospital chaplains will tell you that the work they do does not address purely a person’s physical and mental aspects. I do not want to divide up a human person. Therefore, I believe that the Bill covers people’s needs without inserting the words “physical and mental”.

[Lord Rooker]

My Lords, on balance I agree with the most reverend Primate. I speak purely as a lay person but I am very happy to support the noble Baroness, Lady Hollins. I have no medical training. One almost has to declare that as an interest in this debate. However, mental illness can lead to physical illness and massive social exclusion.

I want to share my experience with the House as it is as relevant today as it was at the time to which I refer. Back in 2003, the then Prime Minister and Deputy Prime Minister commissioned the Social Exclusion Unit to carry out work on how we could attack the cycle of deprivation associated with mental illness. The report was published in 2004 with a 27-point action plan. At that time it was a rule of procedure that a couple of Ministers who were not involved in the matter on a departmental basis chaired the steering group that oversaw the work. I was one of the two Ministers. The other was Rosie Winterton, who is now the Labour Chief Whip in the other place. We launched the report at the headquarters of BT. We did that simply because one of the BT occupational medical staff was on one of the relevant overarching boards, but BT’s record as an employer in relation to the mental health of their employees was absolutely first class. Therefore, we were happy to use the BT headquarters for the launch.

Two departments later, as I travelled round Whitehall departments, I wondered what had happened to the 27-point action plan. These things are developed but the Ministers and civil servants involved with them move on. The relevant civil servants were very surprised to hear from a Minister who had had such a tenuous connection with the work he was asking about. The noble Baroness opposite is aware of this as she was involved with the Social Exclusion Unit. The civil servants told me that the action plan was still in place. I have not familiarised myself with what has happened to it over the past couple of years and I would like to be given an update on it. I would like to share with noble Lords some of the points contained in the factsheet that the Social Exclusion Unit published as they relate to some of the myths that have been mentioned. We need to expose those myths and meet them head on.

Four myths are exposed in the Social Exclusion Unit’s factsheet. I will not detain noble Lords for long as this has been a fascinating debate. The first myth is:

“People with mental health problems are dangerous and violent”.

However, the factsheet adds:

“People with mental health problems are more likely to be the victims rather than the perpetrators of violence. Less than 5 per cent of people who kill a stranger have symptoms of mental illness”.

The second myth states:

“Mental health problems are rare”.

We have heard that myth being busted in tonight’s debate. Indeed, the factsheet states:

“Common mental health problems affect up to one in six of the general population at any one time. Almost everyone will know someone who has had mental health problems at some point in their lives”.

The third myth states:

“People with mental health problems are incapable of work”.

However, the factsheet states:

“US research found that up to 58 per cent of adults with severe and enduring mental health problems are able to work with the right support”.

I will give an example of that in a moment.

The fourth myth states:

“People with mental health problems do not want to work”.

However, the factsheet states:

“35 per cent of people with mental health problems who are economically inactive would like to work, compared to 28 per cent of those with other health conditions. Many successful people have had mental health problems”.

In fact, as part of the exercise, I went for a day and a half around London to look at projects manned exclusively by people with mental illnesses. One was at a restaurant, and the only person involved in the restaurant who did not have a mental health problem was the chef, who had come down from a Park Lane hotel to do the training. Everyone else in the kitchen and the front office had a mental health problem. In fact, nine months later, I took my private office staff for their Christmas lunch there. My visit had been in April and I said, “If I am still around at Christmas we will come here for our private office lunch”. Indeed, we did that. When visiting the three projects, I was driven around by one of the patients. I have never felt as safe in a van driven by anyone else. I had no problem whatever. The idea that normal activity cannot take place or that you cannot be included socially is, of course, a myth.

I want to share one of the other aspects that we put out in a factsheet on this issue. The factsheet states:

“Nearly one-fifth of respondents to the Social Exclusion Unit’s consultation argued that mental health services needed to become more socially focused”—

and more holistic. The factsheet continued:

“GPs issue sickness certificates when they assess that a person cannot perform their usual work. Mental health problems are more likely to be listed on the sickness certificates in the most deprived areas of the country”.

That is another fact that we must take on board.

“It is important to ensure appropriate pathways of care between primary and secondary services; up to 28 per cent of referrals from primary care to specialist services are inappropriate”.

I will not read out all the facts, but shall quote the final two. It is stated:

“The range of services is more limited in rural areas, with specialist services often absent”.

That is the reality of many services, but this is the one that we are dealing with. It continues:

“In 2002, 87 per cent of rural households were 4km away from a GP surgery”.

My final example states:

“A person with schizophrenia can expect, on average, to live for ten years less than someone without a mental health problem, mainly because of physical health problems”.

One therefore has to deal with: stigma and discrimination—and we have heard examples of that; the role of healthcare professionals, which we dealt with in the factsheets relating to employment, welfare and benefits; and the role of families and carers, in particular. I shall leave alone the criminal justice system and other issues. Putting the amendments in the Bill is simple—it does not cost anything in terms of money; it should not upset the parliamentary draftsmen; but it sends a massive signal to the whole structure of the National Health Service that Parliament has highlighted and identified this issue, which relates to both Houses. We do not want it to be put in a backwater. We do not want it to be the first thing that is cut. People have to be treated holistically, because we know that if their mental health problems are not treated properly, physical problems start and we then get the queues at accident and emergency—and other pressures on GPs.

I am therefore very happy to support the amendments in the names of noble Lords from all around the Committee. The work of this Government, which I applaud, was mentioned, and I have provided examples of the work of the previous Government where we were trying to deal with the relationship between social exclusion and mental health. It went right across the board—every government department had a role in this. The issue should not be left just to the health department or the National Health Service. It must be dealt with properly by every department—the economic ones as well as the health ones.

Nursing: Elderly and Vulnerable Patients

Lord Rooker Excerpts

Wednesday 19th October 2011 Lords Chamber

[Earl Howe]

My Lords, we do value the contributions that SENs provide, those who are still in practice. It is certainly the case that the NMC no longer approves programmes for nurses on part 2 of the register and there are no plans to reintroduce educational programmes to part 2 of the register. What we have done is to develop guidance on widening the entry gate to preregistration programmes for those individuals who show the necessary values and behaviours but who otherwise do not possess the traditional academic qualifications. I am aware of the report that my noble friend mentioned. Sheila Try has written to me and I have asked the department to consider the recommendations that she has made.

[Lord Rooker]

Does the Minister agree that it is a very valuable report? If I may remind him, on 31 March in this House when we had a debate on nursing care I asked him if he would meet Sheila Try. Following the question asked by the noble Baroness, I respectfully ask him to study the latest report by this trained nurse, who makes very valid points about what has gone wrong with the training of nurses in the last 25 years.

[Earl Howe]

My Lords, from my reading of the report —and I have looked through it—I think there is much there that we can pick up very usefully, so I agree.

NHS: Standards of Care and Commissioning

Lord Rooker Excerpts

Thursday 31st March 2011 Lords Chamber

[Lord Rooker]

My Lords, there is widespread concern among nurses, patients and relatives about the many incidents of poor nursing highlighted in recent years. There are of course many fine examples of high-quality nursing practice, and I can testify to that from my own family experiences. But action now needs to be taken to improve the state of nurse training and management. Over the past five years, a nurse friend of mine, Sheila Try, has been contacting successive Health Ministers, Select Committees and others with these concerns, as well as the Chief Nursing Officer, all to no avail. They have all failed to see that there is a fundamental flaw in the training and management of nurses and that the image of nursing has been damaged. The Chief Nursing Officer commented to Sheila that these,

“concerns resonate very well with nurse leaders who I have met around the country and with the wide range of people who explain their experiences to the Prime Minister’s Commission, ‘Frontline Care’”.

That is a clear admission of the points that Sheila and other experienced nurses are making.

Sheila Try is a qualified nurse and a health visitor to BSc standard, and a former senior manager and a reviewer for the Commission for Health Improvement. She is not someone who wants to turn the clock back, but she is concerned with the basic essentials of nursing. Last week, she met over 70 third-year degree nursing students at a local university who are due to qualify in August. They stated that they,

“do not feel confident or competent to work as staff nurses as the training has failed to give them the knowledge and skills they need, with clinical placements being too short. There are inconsistencies in clinical practice and Health Care Assistants are doing nursing tasks, including wound dressings, while they as students are doing Health Care Assistant roles (handing out drinks) when they should be being trained in nursing tasks”.

The students are concerned that their competencies are usually decided on just one observation of the skill required, such as catheterisation or wound care. They would prefer a more rigorous check in order for them to feel competent and confident. On learning to drive with an instructor, you do not do a three-point turn only once.

One of the issues lies in the ratio of academic to clinical practice. The time spent in contact with patients is only 15 weeks in each of the first two years over two placements and 21 weeks over two placements in the final year. That is not enough. This is not resulting in well trained nurses capable of giving good, consistent quality care at the point of qualification.

Image and esteem are important. These have been damaged by the practice of not using the title of “nurse” and the poor national uniform that was introduced some years ago. After working for three years to become a nurse, people are told not to use the title, but to tell patients their first name, which is unprofessional. The sign above the bed says, “Your nurse is Susan” or “Mark”, but not “Nurse Jones” or even “Nurse Susan”. That is ridiculous because it is unprofessional and breeds a familiarity that can cause problems.

The uniforms that nurses wear in most hospitals are not very professional, with qualified nurses wearing the same uniform with no difference in design to identify their status. The uniforms are often of poor quality. Nurses have said that they are more like a cleaner’s overalls—that is not to degrade cleaners. This affects not only the image that the uniforms portray to patients and relatives but also how nurses feel about themselves.

One major hospital in the Midlands has recently changed its uniform policy, bringing in colours to identify a nurse’s grade and with the grade embroidered on the uniform. Patients and relatives can now distinguish between a staff nurse and the sister in charge. It has massively lifted morale, because the nurses feel valued. The ward management points that Sheila has asked me to make are exactly the same, word for word, as those made by the noble Lord, Lord Turnberg. The solution, she thinks, is simple: tackle the way in which nurses are trained, with more time spent with patients and less in the classroom.

Nursing needs to be up to date with technology and the changing face of disease and management, but essential care is vital to ensure patients’ safety. A better balance between academia and professional placements, needs to be found. And, yes, Nurse Try would welcome an opportunity to put the case to the Minister direct.