Health: Cancer

Lord Turnberg Excerpts

Monday 14th January 2013 Lords Chamber

[Earl Howe]

My Lords, I am very interested to hear about the treatment mentioned by my noble friend and I can remind her, although I am sure she needs no reminding, that one of the key roles of NICE is to keep evidence of new treatments under review. I do not doubt that as a result of my noble friend’s intervention, it will wish to look at that particular treatment. Pancreatic cancer can grow initially without any symptoms and it is possible that people might not recognise the symptoms. That is why the “Know 4 sure” campaign, which I have mentioned, highlights four key symptoms including loss of weight and pain, which can be symptoms of pancreatic cancer.

[Lord Turnberg]

My Lords, is it not the case that the diagnosis of pancreatic cancer is extremely difficult? The organ lies deep within the abdomen and cannot be seen or felt, so by the time the patient shows symptoms, it is often too late. What we really need is research that will provide us with a biomarker which can be used for screening and early diagnosis. Can the noble Earl tell us whether research along these lines is going on within the NHS?

[Earl Howe]

My Lords, via the Medical Research Council we are supporting a study to assess the effectiveness of a new test called the Mcm5 protein test to see if it can help to diagnose cancer of the pancreas, bile duct and gall bladder. I am also aware of a number of other research projects that my department is funding in the field of pancreatic cancer and I would be happy to write to the noble Lord with the details.

NHS: Hospital Beds

Lord Turnberg Excerpts

Thursday 6th December 2012 Lords Chamber

Asked By

[Lord Turnberg]

To ask Her Majesty’s Government what assessment they have made of the analysis of hospital bed availability in the report Dr Foster’s 2012 Hospital Guide.

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

My Lords, Department of Health data show that the average bed occupancy rate for all beds open overnight has remained stable, at between 84% and 87% since 2000. Rather than being a cause of concern, this indicates that hospitals are making efficient use of beds. NHS hospitals need to manage beds effectively in order to cope with peaks in demand. We expect to see higher occupancy rates in winter, when these demands are at their highest.

[Lord Turnberg]

My Lords, in thanking the Minister for his response and his endurance, I believe that we owe a debt of gratitude to Dr Foster for the report, which shows so clearly how severe the stress is that our hospitals are suffering under. With bed occupancies of 95% to 100% for much of the year for many of the hospitals, there are too often no beds available, staff are rushed off their feet, patients are not cared for properly, infection rates rise and mistakes occur. Given that almost one-third of the patients now in hospital do not need to be there and would be better off cared for in the community, and given that the community services cannot provide that care because they are so underfunded, where are we to get the money from? Simply saying that we can close a hospital or two and slide the money across from a cash-strapped NHS before those services are available will just exacerbate the problem. Would it not be better to use those end-of-year surpluses that we have been hearing about instead of returning them to the Treasury?

[Earl Howe]

My Lords, as I mentioned earlier, NHS underspends are not lost to the NHS—they can be carried forward from year to year. But on his central point, I should make it clear that we are struggling to reconcile the Dr Foster bed occupancy figures with those that we have. Dr Foster has stated that bed occupancy is at a dangerous level, at over 90% for 48 weeks of the year. We are looking closely at that analysis and methodology, but we cannot agree with those conclusions at the moment, given that the department monitors the position on a daily basis during the winter and on a quarterly basis at other times. However, I agree with the noble Lord that there are too many people in hospital. We need to ensure that we move more care into the community. I do not see this as insuperable within the current budgetary expenditure limits.

Social Care

Lord Turnberg Excerpts

Thursday 29th November 2012 Lords Chamber

[Lord Turnberg]

My Lords, I, too, thank my noble friend Lady Pitkeathley for introducing this timely debate. She made a remarkably robust case and we have had some excellent, well informed speeches today. I imagine that it is very hard for the Minister not to have got the message, even though I suspect he does not need it. I, too, am struck by the faint ring of familiarity about this debate.

I want to focus on just two aspects: standards of care for the elderly and the mentally ill, and the integration of hospital and community services. Last week, we had two important reports. One was on the prosecution of those responsible for maltreating an elephant and the other from the Care Quality Commission about the poor standards of care for the elderly and mentally ill—and here, this elephant in the room, although rather more devastating, disappeared from the news rather too quickly.

The CQC painted a picture in which, faced with a rising demand from increasing numbers of elderly patients suffering from an often complex mixture of diseases, many nursing homes and some NHS hospitals were failing to meet basic standards of care. Failing to treat patients with the dignity that they need, failing to feed them properly and failing to care for their basic needs was just too common for comfort. Very importantly, it also found that management and staff vacancy rates were very high. As a result, poorly trained staff were rushed and asked to take on tasks for which they were ill equipped. Patients with complex multiple diseases need well trained staff, and these are in short supply.

All this may sound familiar and similar to repeated reports going back at least 15 years. We have had Age Concern’s report in 1997, the Healthcare Commission in 2004, its successor in 2007, and now in 2012, with so far not much change. If we do not do something now, it will just get worse. So is there anything we can do, apart from putting more money in? Of course, we need more money. Incidentally, the noble Lord, Lord Shipley, spoke about the valuable contribution that the elderly make to society. I do not think that we should forget that the elderly—that is, those over 65—who are supposed to be retired contribute to the national Exchequer through taxed income, and that needs examining. Apart from putting more money in, though, we could look again at the need for the proper training and registration of healthcare assistants. It was a grave error that we were unable to persuade the Government to include in the recent Health and Social Care Act a requirement for healthcare assistants to be trained and registered. I hope that the Minister will look again at the proposal to wait three years before we can revisit that decision.

I turn to the need to co-ordinate care between hospital and community, which has been the subject of some discussion this afternoon, and the need for the seamless care that we are supposed to provide. The problem has been well rehearsed, with elderly patients sitting in acute hospital beds when they would be better off at home or in accommodation more suited to their needs. There are many causes, including, of course, the lack of resources in the community that we have heard about, but often it is the result of failures in communication between the hospital and social services—and it is particularly bad at weekends and holidays. No one seems to take responsibility for this liaison, which is so essential, yet we know what to do, and indeed it is being done in many places. We do not have to go to Canada, where they have set up a very effective multidisciplinary team devoted to integrating care; we have excellent examples in Torbay, which is always being cited, where they have a single, merged care trust. Hereford and Devon have different but innovative schemes for integration. It is not only in leafy, affluent parts of the country where they are making a change; great work is going on in Bradford, Wolverhampton and South Birmingham.

So we know what to do, and one wonders why it is not being done everywhere. Partly it is a lack of lack of local leadership, and perhaps a touch of NIH syndrome—“not invented here”—that sets up resistance to change. Equally, though, we have not seen enough pressure and incentives from the centre. We need to use more carrots and sticks, as well as local leadership. Perhaps the emphasis in the new NHS mandate on care of the elderly and mentally ill will give us the push that we desperately need, and yesterday’s speech by the Secretary of State shows that it has moved up the agenda. I reiterate that we need action on many fronts: to encourage integration between hospital and social services; to ensure the better training and recruitment of healthcare assistants; and, as the noble Baroness, Lady Pitkeathley, pleaded, to have more resources for community services.

Health: Cancer

Lord Turnberg Excerpts

Wednesday 7th November 2012 Lords Chamber

[Earl Howe]

Yes, my Lords. While the document to which my noble friend refers does make explicit that the cancer strategic clinical network will be focused around domain 1, which is reducing mortality, nevertheless improvements to patient experience and patient safety underpin all NHS care and those matters will be similarly embedded in the work of all strategic clinical networks.

[Lord Turnberg]

Does the noble Earl agree that the cancer networks have been invaluable in supporting research into new treatments and that any reduction here would be regrettable?

[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.

National Health Service (Clinical Commissioning Groups) Regulations 2012

Lord Turnberg Excerpts

Tuesday 16th October 2012 Lords Chamber

[Lord Turnberg]

I am afraid that my message tonight will be rather familiar. Although I listened carefully to the noble Baroness, Lady Cumberlege, whom I respect enormously for her experience, I am afraid that I cannot agree with her. Commissioning services in the NHS is an extremely complex activity. For CCGs to make rational decisions, they need the best data and information available about their populations and how to meet their needs.

I understand that economists talk about perfect and imperfect markets. Perfect markets exist where both the purchaser and provider know exactly what they are getting and giving. This is particularly important when we talk, for example, about packages of integrated care, especially care across the hospital community divide. Who better to provide the data and information that CCGs need than those working locally in our hospitals? CCGs should not only understand the needs of their populations; they also need to know something about what can realistically be provided locally to meet those needs. Relevant questions might include whether the local hospital provider has the relevant orthopaedic surgeons who can do specialised and complicated knee or hand surgery, whether it has the oncologists and haematologists to deal with all cancers or only some, and whether it has the relevant up-to-date scanning facilities. There will be a dozen other questions that only local knowledge can answer.

It seems obvious to many in the field that local specialists and nurses from the local trust are in much the best position to provide the answers, and to engage constructively with GPs in the provision of services. The idea that there is a conflict of interest appears to me to be nonsense. Of course there is local interest. Local consultants and nurses are there to provide local knowledge and information. The idea that consultants and nurses from elsewhere can be parachuted in to provide local information is asking too much, quite apart from the problem of whether another trust will be willing to allow its staff time off to travel around the country.

We do not want or need disinterested clinicians in the CCGs; we need interested clinicians. I hope that the noble Earl will listen if not to my noble friend Lord Hunt then to the royal colleges, which are very strongly in favour of local input from the secondary sector.

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

My Lords, I begin by thanking the noble Lord, Lord Hunt, for tabling this Motion, which provides a welcome opportunity to clarify the Government’s intentions in making these regulations on clinical commissioning groups—an opportunity that I feel is rather necessary in the light of some of the speeches that we heard this evening.

The regulations set out the legal requirements on the size and membership of a CCG’s governing body. Together with amendments made to the National Health Service Act 2006 by the Health and Social Care Act 2012, they provide a clear legal framework within which CCGs can appoint their governing body and develop appropriate governance arrangements. CCGs will be different from previous commissioning organisations. They will be built on the GP practices that together make up the membership of the CCG. These member practices must decide, through developing their constitution, how the CCGs will operate. They must ensure that they are led and governed in an open and transparent way that allows them to serve their patients and population. It is vital that CCGs are clinically led, with the ownership and engagement of their member practices, so that they can bring together advice, as noble Lords emphasised, from the broadest range of healthcare professionals to influence patterns of care and to focus on patients’ needs.

That is a necessary preface to the subject that has been the focus of much of tonight’s debate: the role of the governing body of the CCG. Following the NHS Future Forum, we introduced measures in the then Health and Social Care Bill to strengthen governance arrangements for CCGs, primarily through the requirement for each CCG to have a governing body that would have responsibility for ensuring that the CCG operates effectively, efficiently and economically, and does so with good governance. As we discussed during the passage of the Bill, our intention was to provide the public with greater confidence that CCGs would have suitable governance arrangements in place, including independent views and strong leadership, and would have proper checks and balances for the stewardship of public money. CCGs will be the guardians of significant amounts of taxpayers’ money. It is therefore only right that there are strict requirements in relation to governance, probity and transparency of decision-making. We must balance the benefits of the clinical autonomy of doctors with a robust management of potential or actual conflicts of interest. It is essential to get this right, and that means a proportionate and reasonable approach.

The Health and Social Care Act already provides real safeguards against conflicts of interest. The CCG must make arrangements in its constitution for managing conflicts and ensuring the transparency of its decision-making process, and it must have appropriate governance arrangements, including a governing body with lay members and other health professionals. These arrangements will be scrutinised by the NHS Commissioning Board as part of the process of ensuring that a CCG is fit to be established as a commissioner.

The requirements in relation to the secondary care doctor and registered nurse are therefore part of an overall package of requirements to ensure that they operate with good governance. We made clear in the Government’s response to the NHS Future Forum in June last year that neither the secondary care doctor nor the registered nurse should be from a local provider in order to prevent any potential conflicts of interest. We did that because a conflict of that nature would be a constant issue for a secondary care provider, given that CCGs will be responsible for commissioning the vast majority of hospital services. In contrast, CCGs will not commission primary care—that will be the responsibility of the NHS Commissioning Board. Therefore, for the most part, GPs on the governing body do not have a conflict of interests, and in any case GPs will not necessarily be in the majority on a CCG governing body.

On any occasion where CCGs consider commissioning local community services, arrangements must be made to manage both actual and potential conflicts of interest in such a way as to ensure that they neither affect the integrity of the CCG’s decision-making process nor appear to do so. The NHS Commissioning Board has issued guidance and a code of conduct for CCGs to deal with that set of circumstances.

What then is the role of the secondary care doctor and registered nurse on a CCG governing body? Their primary role, along with other members of the CCG governing body, will be to ensure that the governing body exercises its functions effectively and with propriety and absolute fairness. However, each member of a governing body will be expected to bring additional perspectives to underpin the work of a CCG. For the specialist doctor and the registered nurse, this perspective will be to provide a view beyond primary care and a broader understanding of health and social care issues—specifically patient care in a secondary care setting for the specialist doctor and, for the nurse, the contribution of nursing to patient care.

That is different from the role of clinicians in commissioning. Involving clinicians in commissioning has been one of the primary goals of our healthcare reform. I need to underline that as it is very much separate from the specific role of the CCG governing body. The detailed work on service design will not be done by the governing body of a CCG: rather, it will be done by the CCG itself, working with clinical networks and other multiprofessional groups. The governing body will have oversight of the governance of this decision-making process.

CCGs have a legal duty to obtain advice from people with a broad range of professional expertise when carrying out their commissioning responsibilities. My noble friend Lady Williams was absolutely right in saying what she did on that score. This could involve, for example, a CCG employing or retaining healthcare professionals to advise the CCG on commissioning decisions. Local knowledge and an in-depth understanding of local health issues will come not only from local GPs and their member practices but from other local clinicians, including local secondary care clinicians, who will work with CCGs to review local health needs and design local services. So the arguments presented by the noble Lord, Lord Hunt, and others around excluding local secondary care clinicians from the governing body as affecting the quality of the CCGs commissioning are wholly misplaced.

As to the restrictions placed on councillors preventing them from serving on CCG governing bodies, I start with a point of principle. We have been very keen from the outset of our reform programme to limit political interference in the day-to-day activities of the NHS. We have always been clear about that. Consequently, in addition to local authority members, we are also excluding MPs, MEPs and London Assembly Members from serving on a CCG governing body. However, our proposals do not mean that councillors are excluded from CCGs. A local councillor may still serve as a member of a committee or sub-committee of a CCG governing body, with the exception of the remuneration committee, as long as a CCG has set out the arrangements for such a committee in its constitution. A councillor falls within the description of an individual “specified in the constitution” as being eligible for membership of a committee. A CCG may provide in its constitution for any function of the governing to be exercised on its behalf by a committee or a sub-committee of the governing body, or by any individual of a description specified in the constitution. These arrangements could therefore allow for a local councillor to play a pivotal role in the CCG’s decision-making without formally being on the governing body.

NHS: Professional Qualifications Directive

Lord Turnberg Excerpts

Monday 15th October 2012 Lords Chamber

[Earl Howe]

My Lords, it is important to understand that the EU social partner process, which is driving the discussions at the moment and has been extended to 31 December, is autonomous. It operates independently of both the Commission and the Council and the Government have no formal role in any social partner negotiations. Having said that, we have made it clear to the Commission and to partners in Europe that securing long-term sustainable growth has to be the EU’s key priority. We will continue to work with our partners to ensure that EU measures support labour-market flexibility and do not impose significant costs on member states or burdens on business. The Government would welcome proposals coming forward that would preserve the right for all workers, including those in the NHS, to choose the hours that they work, including in particular flexibility in the areas of on-call time and compensatory rest as well as the preservation of the individual opt-out.

[Lord Turnberg]

Does the noble Earl agree that the working time directive as it now operates is detrimental both to patient care and doctor training? Is it not time that we stopped at least the nonsense of counting time in the 48 hours as time when one is on call, even though one may never be called? Will the noble Earl make sure that the case is made to the EU that at least this part of the directive is rescinded?

[Earl Howe]

The SiMAP and Jaeger judgments are very much the focus of our representations to the EU Commission. The disquiet about those judgements and the inflexibility that they have brought is shared by other member states. It is also important to recognise that none of us wants to go back to the past, with tired doctors working excessive hours. Tired doctors make mistakes; there is substantial evidence to support that. No one wants or deserves to be treated by tired doctors. There is a balance to be struck. The inflexibilities in the directive need to be addressed, but we should not go back to the bad old days when doctors became too tired to do their work.

NHS: Specialised Services

Lord Turnberg Excerpts

Wednesday 18th July 2012 Lords Chamber

[Lord Turnberg]

My Lords, I am sure that we are all grateful to the noble Baroness, Lady Jolly, for introducing this debate and setting out the issues so clearly. There is deep concern among the support groups that speak for patients with rare diseases that the loss of this advisory group, newly formed as it is, will be a retrograde step and create confusion and a loss of a valuable asset. I have no doubt that the Minister will try to reassure us by saying that this will all be taken care of by the commissioning board. There is little or nothing in the Health and Social Care Act, or in any other document I have seen, that offers any confidence yet that this has been given enough serious attention. I look forward to him saying rather more than we have heard so far when he comes to round up.

It is the case that the advisory group has been widely regarded as doing a marvellous job. It is recognised not only by the NHS and by patients, but also by other countries as a model for the way services for patients with rare diseases should be provided. It does this by having developed a rational framework that takes account of best practice and societal and health gains. It has done so in a way that is efficient and at a reasonable cost.

I would like to illustrate this by using the example of the group of orphan, or very rare, diseases that rejoice under the name of lysosomal storage diseases. These include Gaucher’s disease, Hurler’s syndrome and a number of others. They affect few patients, almost all in childhood. An average GP in an average year is unlikely to see a case. If she is faced with a case she is unlikely to know what to do about it and left to herself is likely to be reluctant to fund the patient’s care.

These are the sorts of cases that have to be funded and commissioned centrally and cannot be left to CCGs. Only when sufficient knowledge and expertise are available can commissioning be rationally arranged. Here, the advisory group has been invaluable. It is not simply commissioning that is needed. The provider services for rare diseases must be distributed in a limited, rational number of places to make the best use of limited resources. Specialised services for children with lysosomal diseases are located in only three places: London, Birmingham and Manchester. For adults they are located in five places around the country. Only by limiting the number of sites can you expect to develop a critical mass of specialised doctors, nurses and other healthcare workers to provide the best possible care. They are also the places where teaching and research into these diseases can best be done.

That is one example. Similar needs apply to a much larger number of diseases, each of which occurs rarely. The Genetic Alliance UK is an umbrella organisation that brings together over 150 patient-led charities, each set up to support these patients, again mostly children, with genetic diseases. Most of them fit into the category that is covered by the advisory group; that is, they affect fewer than 500 patients a year and currently the advisory group covers about 70 specialised services. For these patients, the advisory group has made all the difference. Yet now there is much concern that all this expertise will be pushed out and dissipated as the commissioning board takes on its multitude of responsibilities.

Can the Minister reassure us and them that there will be a rare disease plan in the mandate for the board? Will the board have access to the specialised expert advice that is so valuable and ready made for this purpose in the advisory board? I am sure that he is well aware of the need and requires no prompting from me on this, but I hope that he is going to be able to say something today that will help allay these concerns.

Health Research Authority (Amendment) Regulations 2012

Lord Turnberg Excerpts

Wednesday 13th June 2012 Grand Committee

[Lord Hunt of Kings Heath]

My Lords, I should start by declaring interests as the chair of a foundation trust, as a consultant in the health service and as a trainer with Cumberlege Connections Ltd.

As well as moving this Motion, I shall also speak to my second Motion, which also relates to the Health Research Authority.

On the face of it, the regulations and order are unexceptionable and they passed through the Secondary Legislation Scrutiny Committee without comment. They provide for the board to be reconstituted with independent non-executives and an independent chair.

The responsibility that falls to the members of the authority is indeed weighty. The noble Earl, Lord Howe, has a long-standing record of commitment to health research, which is considerably reassuring to all those with an interest in this area. I have no doubt at all that health research is as important to the economy of this country as it is to the quality of patient experience and outcome. Indeed, embraced with the high quality of life sciences in the UK, it is crucial that we prioritise health research to the fullest extent possible. Certainly my experience in chairing the Pharmaceutical Industry Competitiveness Task Force some years ago convinced me of the essential link between the health of the person, the health of the NHS and the health of the economy, and that is why I think it is so important for the National Health Service to support health research. Our debates during the passage of the Health and Social Care Bill indicated the strength of support for research and for the Secretary of State’s responsibility for it to Parliament.

The HRA has been set up to protect and promote the interests of patients and the public in health research. The aim is to lead to the creation of a unified approval process and to promote consistent and proportionate standards of compliance and inspection. The HRA has a number of functions, including being the appointing authority for research ethics committees in England, and it provides the National Research Ethics Service. Also, by agreement with the devolved Administrations, it supports a UK-wide system for ethical review in the UK. It has an important ongoing programme of work and it also provides the integrated research application system through which applications for regulatory and governance approvals of health research are made in the UK. It also agrees plans to provide a platform for the unified approval process from the IRAS, as it is known.

I turn to the details of the regulations and order. I ask the noble Earl whether it is intended that the non-executives should be a majority on the board. I should also like to ask him about the Government’s intention regarding the publication of draft clauses to establish the HRA as a non-departmental public body. I do not know whether he can give any indication at all about the timing of and commitment to the eventual legislation that has been promised. Will he also comment on the Government’s approach to, and policies for, enhancing health research in the UK?

How are we to ensure that we make the most of the excellence of our life sciences? Can the Minister give some reassurance about the priority to be given to research by the NHS Commissioning Board? Does he believe that academic medicine is given sufficient support by the National Health Service? Is he confident that the HRA has the capacity to streamline research application processes? That point has been made to me by a number of organisations that have been interested in the order and in our debate.

The noble Earl will be aware of the continuous debate over probably the past decade about the bureaucracy involved in the application processes and a feeling that the UK has lost its competitive edge because of that. I know that the previous Government and this one have continued to do work in this area and I wonder whether he can report any further progress. I should like him to comment on whether he believes that the UK will be able to maintain a competitive edge in research in the years to come and whether he believes that the intention is to maximise large-scale patient recruitment.

Alongside that is the importance of site selection and the question of whether it is going to be easier for applicants in the future to conduct multi-centre research. My understanding is that one of the problems is that applications for multi-centre research have to go to the individual institutions concerned, which can sometimes hold up approval. My understanding is that there is going to be a concerted attempt to speed up that process. Again, if the noble Earl could give some comfort there, it would be much appreciated.

It is also important that the National Health Service recognises the importance of its role in supporting, developing and encouraging research. That is partly to do with the appointment of academic clinicians within the National Health Service, partly about a willingness to accept that it is important for clinicians to take part in research and also about the importance of ensuring that individual bodies in the NHS have good processes for offering opportunities for clinical trials. Any positive messages that the noble Earl could give on that would be appreciated.

On the private sector, if the Government are to develop a market in the NHS, what obligation will there be on private companies to maintain and support research if they win contracts to provide services to patients? I attended the launch of the Clinical Practice Research Datalink, at which the noble Earl spoke and which I thought was very impressive. How does he think this will link to the work of the Health Research Authority? I was very taken with the potential to use such a wide database of anonymised information, which the NHS can provide. The issue that arose from that debate and that launch is whether we are really able to make the most of the opportunity that is being given.

My final point brings me to value-based pricing. My understanding is that the Government still intend to introduce value-based pricing. I express again to the noble Earl my reservations about the impact of that on flexibility within the pharmaceutical industry and the pricing structure, which might then have an impact on their willingness to invest in R&D in this country. The Department of Health, I understand, is still a sponsor of the pharmaceutical industry. It is, of course, always torn; there is always a tension between the cost of drugs to the NHS and sponsorship of the industry. I hope that we are not going to see short-term decisions taken in relation to the cost of drugs at the expense of long-term investment in R&D in this country. Value-based pricing is a quite complex and technical subject, but it is important that there is transparency about the decisions that lie behind a move to value-based pricing and its likely impact on the UK as a whole, and not just the cost of drugs to the NHS. I beg to move.

[Lord Turnberg]

My Lords, the development of the Health Research Authority has been extremely welcome and the research community is very grateful that we have it; it has a number of very important roles in relation to the research ethics committees.

My questions relate to the extension of those functions as it plays out, because, of course, the Academy of Medical Sciences report expected this to apply to rather more than just the ethics committee; they relate to what is planned for it as it moves along. In particular, when is it likely that the ethical approval for the use of patient data—not anonymised data but unanonymised data, if there is such a word—which are currently with the Secretary of State, will come under the jurisdiction of the new authority? My noble friend Lord Hunt referred to the major hurdle that is put in the way of research and which takes time: the problem of getting approval from several health authorities or trusts. At that level, it is unclear whether the Health Research Authority will have any power over that process. I would like to hear more about what is intended for the future, now that we have it set up. I know that there are intentions and I would like to hear more about them.

Health and Social Care Bill

Lord Turnberg Excerpts

Monday 19th March 2012 Lords Chamber

[Baroness Masham of Ilton]

My Lords, the Health Protection Agency is held in high esteem throughout the world. It does the most important work in protecting society from infections and epidemics. The National Blood Service can be the blood of life. It is vital. Can the Minister give an assurance that the HPA will not be downgraded in any way? I support Amendment 14 and hope that the Minister will accept it. If he does, that will give some assurance to some of the people who have concerns about the changes. With so many complicated conditions, research should not be restricted and funding for this must be free and seamless.

Will Public Health England work with other countries? Infections have no boundaries. One never knows what is around the corner. The work of the body should be as independent as possible. Otherwise, we will lose some of our brilliant researchers to countries which will give them more freedom.

[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.

--- Later in debate ---

We are now in the process of establishing a detailed framework for the way PHE will operate which will address its relationship with local and central government, as well as with the general public. That framework will, of course, be published. However, I can say now that as well as appointing the board and chair we will take a number of other steps to highlight and support the operational independence and transparency of PHE.

[Lord Turnberg]

I am grateful to the noble Earl for giving way. Will this board be an advisory board or the board?

[Earl Howe]

I think that the noble Lord asked me whether the board will be an advisory board or a board. Its function will be to provide advice. It will be a board, but the Secretary of State and the chief executive of PHE will look to the board for that robust challenge and advice that a public health service needs.

Health and Social Care Bill

Lord Turnberg Excerpts

Tuesday 13th March 2012 Lords Chamber

[Baroness Masham of Ilton]

My Lords, we are once more discussing the important matter of the power to regulate healthcare support workers in England. I am pleased to have added my name to the amendment. I spoke about this at Second Reading and in Committee. I agree with the Royal College of Nursing that mandatory regulation and registration of these support workers is important in order to safeguard patients’ safety and to ensure standardised training so that there is a skilled and suitable workforce.

I have yet to meet anyone who understands the situation who disagrees about this, except some members of the Government. Nurses who have been struck off their register can then work as care assistants—again, putting patients at risk. The Government are considering a voluntary register, but this will not cover the undesirable people who get jobs as care assistants because they cannot get employment elsewhere. Clinical physiologists have found that self-regulation, which they have had since 2001, is not as effective as statutory regulation. Should we not learn from this?

We know of the tragic cases at the Mid Staffordshire NHS Foundation Trust, where the deaths of hundreds of patients were associated with bad care. It makes one wonder how Mid Staffs was approved for foundation status. We also know of the horrific bullying by care assistants at Winterbourne View care home at Bristol. Since Committee, we have heard of Malcolm Cramp, who was convicted of seven counts of ill treatment and sent to prison for abusing dementia patients at Brockshill Woodlands, a care home in Leicestershire. In another case, Sean Abbott, a caseworker, was jailed for a year for assaulting vulnerable residents at St Michael’s View care home in South Shields. Daphne Joseph, another person at that home, was given a nine-month suspended sentence when she admitted the ill treatment and neglect of a patient, who died. The judge at Newcastle said that she had not had enough training. He also said that she was operating,

“in a regime which was inadequate and not fit for purpose and in which there were too many patients, not enough planning, and too few staff, let alone trained staff”.

This concerning situation is happening up and down the country. Is it not time that better safeguards for patient safety were put in place? Statutory regulation and the registration of healthcare workers could help. Many of them are now undertaking procedures that only doctors and nurses did but they have little training to do it.

[Lord Turnberg]

My name is attached to this amendment, which I believe is an extremely important one. I find myself in the somewhat unusual—indeed, unique—position of, for the first time, not being able to agree with the noble Lord, Lord Newton. We have had many debates in this Chamber in which the standards of care in our hospitals and nursing homes have been examined and, in too many places, found wanting. We have had many other reports showing the same thing. Many institutions and many care workers are outstanding but, as we know, there are too many places where patients are neglected and their basic needs not addressed.

Of course, all these failures cannot be put at the door of healthcare support workers. Where they occur, these failures are systemic and go right across the hospitals and homes. The employers, doctors, nurses and everyone in the institution should bear responsibility. However, all too often it is at the level of the healthcare support worker—who provides the basic care of feeding, washing, toileting and a host of other responsibilities and is often in closest contact with the patient—that we hear complaints from patients and their families. Healthcare support workers are at the end of the line and are too often left to themselves.

I fear that when we lost our SENs—our state-enrolled nurses, who did not need a university degree—in 2000, we lost a group of professionals who were trained and educated to do their job. If we are to regain the sense of professionalism and pride that my noble friend talked about that full registration would bring to a cohort of well trained and regulated young men and women, then we must move to full and proper registration. I do not believe that a voluntary register gives that degree of control. It certainly does not give sufficient recognition to the importance of the job. I hope that the Minister will agree.

[Lord MacKenzie of Culkein]

My Lords, I apologise to the House for not being here at the start of this amendment. Unfortunately, I had to seek the help of the health service this morning for a touch of bronchitis. I apologise particularly to the noble Baroness, Lady Emerton, for not being here on time.

I strongly support the amendment. I have spoken on this matter on each occasion that the call for statutory regulation has been debated in this Bill. I also referred to this issue in the debate on front-line nursing which we held last December.

The Government argue that voluntary registration is sufficient unto the day. I beg to differ strongly. As a nurse, I cannot agree that the present state of affairs should continue, and I do not think that I am a lone voice. The health committee in another place, the Nursing and Midwifery Council and all the staff organisations representing healthcare assistants all support statutory regulation.

History has a habit of repeating itself—wheels turn full circle. In the 1930s, financial pressures brought about huge increases in the numbers of support workers, or assistant nurses, as they were called. There was no provision then for regulation. It took the work of two committees—the Athlone Committee in 1937 and the Horder Committee in the early years of World War II —to lead to legislation which allowed for registered and regulated status for assistant nurses. We had state-enrolled assistant nurses as a consequence, and I think that it was in the early 1960s that the word “assistant” was removed from the title.

By the 1980s, the role of nurses on the first and second parts of the register was blurred. As a consequence, and as part of the move away from hospital-based training into higher education, the enrolled nurse training for first-level nurses was discontinued. It was always a mistake to leave that vacuum when the enrolled nurse training ended—a matter referred to by my noble friend Lord Turnberg.

The outcome is entirely predictable. That wheel has, indeed, turned full circle. We have had, again, huge increases in support staff; we have, again, financial stringency; and, as in the 1930s, there are now campaigns for proper regulation and training for those who assist nurses. However, the roles have been blurred this time not between the enrolled nurse and the registered nurse but between the healthcare assistant and the registered nurse. That is the very issue that led to the ending of enrolled nurse training, but this time there is no fall-back—there is no fail-safe for the patient—because there is no standardised training; there is no legal obligation in the Bill to require standardised quality training; and there is no obligation for registration, regulation, accountability and, not least, a code of conduct for support staff. The amendment in the name of the noble Baroness, Lady Emerton, will do much to resolve that issue. Most importantly, it is about patient safety. The amendment is specific—it is not about all support workers working in the hospital service or care homes; it is about those staff to whom are delegated what are, by any standards, nursing duties of registered nurses. It is not good enough for the Government to keep saying that voluntary registration is sufficient and that everything else is a matter for employers.

That is the present situation and it is far from satisfactory. I suggest that it will get worse in the future. We all know that the ratios between nurses and healthcare support workers are often worse than the generally accepted 60:40. The financial squeeze will certainly mean further changes—and not for the better. Voluntary registration does not work. For a long time, for example, clinical physiologists have been trying to make the case to the Government that voluntary registration has failed, and the coalition Government have turned their face. The leaving-it-to-the-employer approach will leave the patient at risk, and neither the registered nurse nor the healthcare support worker is protected in these situations if something goes wrong. Increasingly, the employer will be exposed as well, as there may well be more cases such as that of Mid Staffordshire as a consequence of financial pressures and getting skill mixes wrong—not least when these decisions are made by human resources people with little or no proper nursing input.

In my submission, the patients are not always clear about who is providing care for them. My recent six months as a patient in two teaching hospitals confirmed that—virtually everyone in a uniform was a nurse to most patients. That is not surprising. Healthcare assistants routinely carry out observation rounds; they carry out clinical procedures such as cannulation and catheterisation; they give injections; and they undertake venapuncture to take blood. That is just to name some of the procedures that they might carry out. Patients would be very surprised if they were told that the staff carrying out these clinical procedures were neither regulated nor registered.

Regulation and standardised quality of training does not, in itself, guarantee that matters will not sometimes go wrong. That can—and does—happen in all regulated professions. However, statutory regulation and registration is the best way forward to give better surety to patient safety. I strongly support these amendments.