Care Bill [HL]

Lord Willis of Knaresborough Excerpts

Tuesday 4th June 2013 Lords Chamber

[Lord Willis of Knaresborough]

My Lords, I support Amendment 12 in particular. I declare an interest as an honorary fellow of the Royal College of Nursing.

When I was preparing the Commission on Nursing Education report, although we were looking at pre-registration, one of the key elements that came up time and again was that nurses were leaving their training and going into settings, within NHS tertiary care settings, primary care settings and, in particular, community settings and domiciliary settings, where the notion of continuing professional development was non-existent. People were finding an immediate barrier to even asking questions about doing things in a better way. The way you overcome that is by doing exactly what it says in this amendment. You put at the very heart of your organisation the fact that you continue to develop. Even preceptorship, the year after training, was given scant regard in many places because the nurses were so busy doing their day-to-day tasks that there was not time for management to put it in. My argument is that without putting in that training, you are less efficient, you give poorer care and ultimately the whole organisation suffers. I hope that my honourable friend will take on board this crucial business about ensuring that Health Education England is not just about training at the base level, but is about continuing to train people throughout the whole of their professional lives.

[Baroness Emerton]

My Lords, I will add to what the noble Lord, Lord Willis, said. A lot of work is being done on the appraisal system, but without the appraisal system leading into continuing professional development, professional development becomes ad hoc. A lot of work is being done by the noble Baroness, Lady Cumberlege on appraisal, and I believe that some work is being done by the department as well. If we could link this work with continuing professional development, I think that that would be very helpful.

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[Lord Willis of Knaresborough]

I speak to Amendments 15 and 36 in my name and those of the noble Baroness, Lady Emerton, and the noble Lord, Lord Patel. On Amendment 15, one of the most daunting tasks for Sir Keith Pearson and his staff at Health Education England is the challenge of workforce planning. I do not believe that anybody has done that right in the health service since its creation. The noble Lord, Lord Turnberg, rightly pointed out that it takes a good five years to get a junior doctor. It takes 10 years to get a consultant. For senior consultants, we are probably talking about 12 to 15 years. For anyone to sit down in Richmond House or elsewhere and start to plan what is going to happen in 10 to 15 years is an incredibly difficult task, and no one has managed it yet.

Secondly, looking ahead, if 10 or 15 years ago you were planning a workforce, you would have automatically said that we need a supply of certain groups of professionals and that, provided we can get that supply, we will be reasonably okay. We can bring in a few from abroad, usually the Commonwealth, and often denude the poorest countries in Africa of their health staff and get the nurses from the Philippines. That enabled us to get by.

What we are doing now—I think that the Minister is acutely aware of this— is planning for a health and care service the like of which we have never seen. There will be research developments, especially in areas such as genomics and regenerative medicine, which will create cures for major debilitating diseases and, at the same time, give us innovative ways of dealing with people’s long-term chronic illness in their homes by self-management. Therefore, the professionals and the care support workers for those professionals working within the NHS have to be of a calibre and to have a flexibility the like of which we have never seen.

We have tabled Amendment 15 because HEE needs all the support that it can get in obtaining representation to support it to look ahead. By that, I am talking about the research base. We have to consider what medicine will look like, what cures will look like and what the demographic requirements will be in 10 or 15 years’ time—or even in five years—to plan the workforce. I hope that in reply, the Minister can reassure the House that there is that sort of long-term planning for a workforce not like today’s. We are not planning the workforce of yesterday with different numbers, we are looking at a totally different workforce for the future.

Amendment 36 is a probing amendment to gain assurances from the Minister that HEE will receive representations from organisations other than the medical royal colleges. The Explanatory Notes to the Bill specify only medical royal colleges in paragraph 515. We therefore ask that that be updated to reflect all royal colleges.

In the Francis report, one of the criticisms of the Royal College of Nursing—I refer to it specifically—was that there was a conflict between its role as a trade union and its role as a royal college. The Government and Health Education England have an opportunity to challenge it on that role and to make sure that it steps up to the mark as a royal college. Only by doing that will it actually serve the nursing workforce to its true extent. We have seen that with the medical royal colleges, and, by including royal colleges in this particular amendment, which would include the Royal College of Nursing, we are sending out a challenge to the RCN that it, too, must be part of this game rather than a bystander.

[Baroness Wall of New Barnet]

My Lords, I, too, support Amendment 36. I just want to pick out something that the noble Earl mentioned a little while ago in response to another question from me. He mentioned the work being done by Skills for Health and Skills for Care. Certainly in the context of this amendment—which, I agree, is a probing amendment—alongside the royal colleges and the other professional bodies, the work that Skills for Health and Skills for Care are doing is hugely important. Can the noble Earl enlighten me on what relationship Health Education England will have with those bodies? For instance, the noble Lord just referred to what the future looks like and what Skills for Health in particular is doing alongside Skills for Care. It is looking at what provisions there are for apprenticeships inside the health service, which is hugely important and allows people to develop from smaller roles to bigger roles over time. I wonder how, in the scheme of things, that relationship exists, how close it is and what influence Skills for Health and Skills for Care have, so that they are not working in opposition but are working integrally with what HEE is doing.

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[Earl Howe]

I am grateful to the noble Baroness. I have to go a little further, so if I may I will cover her point in a moment.

Amendments 40 and 42 to 46, tabled by the noble Lord, Lord Hunt, and the noble Baroness Lady Wheeler, focus on the need for expertise on the local education and training board. Specifically they seek to change Clause 91(3) to require a LETB also to have as members persons who deliver education and training to healthcare workers, a registered nurse, persons with experience in staff groups that are not professionally registered, healthcare workers who receive education and training from within the area, patients and carers or their representatives, and a representative of the local health and well-being board.

I fully expect Health Education England and the LETBs to work closely with and seek advice from a range of key stakeholders, including those providing education and training, members of staff, patients and carers. That requirement is clearly set out in Clause 89. I appreciate the position of noble Lords but do not agree that we need to specify all these groups in the governance structure.

In establishing the LETBs, the Government are committed to driving up standards and the quality of education and training provided. I suggest that that can happen only if those directly involved in the provision of education and training are at the heart of the new system. By their very nature, local education and training boards will be representative of local healthcare providers, who play a critical role in educating and training our workforce. They are the health professionals who support and supervise clinical placements and training programmes across the country, providing professional leadership and support to students and trainees.

If we mandate a requirement for a nurse, others will ask why there is no requirement for a doctor, a dentist, an allied health professional or any of the many other professions. I completely agree that these professions, and the bodies that represent, regulate and support them, need to be closely engaged in the work of the LETBs, but it is not practical to require all of them to be members of the board. The Bill makes provision in Clause 91 for those involved in the provision of education and training, such as universities, to be eligible to sit on an LETB. We know from the 13 LETBs established by the HEE special health authority that all of them have a university representative on their boards, and many different health professionals are also represented on them.

HEE will appoint independent chairs of the LETBs. These will be people who are not directly involved in the delivery of health services, or education and training, in the geographical area. Having an independent chair will ensure that the local education and training board acts independently and in the interests of all healthcare providers represented.

To be appointed in the first place, local education and training boards will need to demonstrate to HEE that they have the right governance arrangements and the right mix of people on their boards with the necessary capacity and capability. In going through that process it will be for HEE to assess whether the local education and training board has the right mix of skills, knowledge and expertise with which to carry out its functions. However, as the intention is for local decisions on education and training to be made by the LETBs, it is important that we give them the flexibility to determine who sits on their boards.

To sum up the position, I can reassure noble Lords that LETBs are already developing strong partnership arrangements in their patch to engage with all education institutions involved in education provision in their area. The HEE special health authority has reinforced the importance of this in the appointment criteria that it set the LETBs, which have to be approved by the Secretary of State. These demand that LETBs demonstrate meaningful engagement and collaboration with many stakeholders with an interest in education and training, including students and trainees, and patients and carers. As a result, they are putting in place appropriate advisory and partnership arrangements to support the decision-making of the local education and training board.

[Lord Willis of Knaresborough]

Perhaps I may interrupt the Minister and come back to the important point made by the noble Baroness, Lady Wall. In responding the Minister has yet again constantly referred to what I would call professional organisations. There are nearly 1 million healthcare support workers in the care and the health sectors. Many are untrained. Most are unregulated and unregistered. The two organisations that are providing basic skills, Skills for Health and Skills for Care, were dreamt up within the department. They did not widely consult before they put their forward their proposals for training programmes. The Nursing and Midwifery Council was never asked about the standards for Skills for Health. Will the Minister say who will be consulted about training the people who do so much of our basic social and healthcare—those who are called healthcare support workers?

[Earl Howe]

I fully recognise the importance of the healthcare support worker sector. I can reassure my noble friend and the noble Baroness, Lady Wall, that Health Education England will be working closely with the sector skills councils, Skills for Health and Skills for Care. I note my noble friend’s scepticism about those bodies, but I do not share it. They have done a pretty fine piece of work and the fruits of it will be apparent over the coming months. HEE will need to do that if it is to perform its role as fully as it should to plan and shape the development of the entire workforce. If by some mischance it were to neglect that aspect of its work and not focus on improving training standards for the health and care support workforce, it would lead to a very unbalanced and unsatisfactory position. Therefore, we are very clear that this should be part of the remit of Health Education England. I hope that that is sufficient reassurance for noble Lords.

The noble Lord, Lord Hunt, asked about health and well-being boards being represented on LETBs. There is a clear commitment in Clause 93 for LETBs to consult health and well-being boards in the development of their plans.

My noble friend Lord Willis asked how Health Education England’s workforce planning will take into account new innovations. Workforce planning is a key focus for Health Education England. It is not about churning out the same old numbers but about working with service commissioners, service providers and other partners such as royal colleges to understand how the workforce needs to respond to service change. This means taking account of technological, pharmaceutical and other advances, and having a flexible workforce that is able to adapt to those innovations.

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[Baroness Emerton]

Amendment 19, on the importance of practical-based training in the education of clinicians, follows on from what the noble Baroness, Lady Wall, and the noble Lord, Lord Hunt, have just said. Because we are moving so quickly in healthcare delivery and the integration and multi-professional working, perhaps we should be looking at how holistic care, which is what I think is being referred to—the ability to see the patient pathway from primary care through to hospital care and back out to primary care—can be a pathway that nurses in particular are trained to be able to execute and to ensure that the transition from one to the other is smooth and without hiccups.

The complaint that we are getting at the moment from the public is that there is a complete block in some areas where the staff are just not aware of what the discharge policies should be and what is at the other end. That picks up the point raised by the noble Lord, Lord Hunt, about the practical skills and the need to look at the curricula from the academic area and put them back into the practice area.

Amendment 14 concerns HEE’s staffing and skills mix in carrying out its functions. When we look at the skills mix, what we are really looking for is an evidence base. We want to look not at static numbers but at evidence based on the safety level. If the minimum is based on the safety level, we are looking at something that can be a useful guide on which to base our working.

[Lord Willis of Knaresborough]

My Lords, I shall speak to Amendments 26 and 33. Like the noble Baroness, Lady Emerton, I also emphasise the importance of Amendment 19. While it is a rather small amendment, it has huge significance.

Talking to people from Health Education England recently, I was struck by the desire in the Francis report about the whole issue of practical training. When a significant amount of the training of medics, doctors and nurses is carried out in practical situations, one asks how you can get the sort of situations that the noble Lord, Lord Hunt, referred to. When nurses spend 50% of their time in practical situations, how do they come out of their training not ready to be deployed in certain areas? To be fair, when you see the time and the effort that is put into mentoring in many of these settings and the quality of that mentoring, you start to realise that there is a big problem. I hope that on Report we can bring back some of the issues relating to mentoring, or at least get some satisfaction from the Minister that this issue will be taken incredibly seriously in health education. If it is not, we will continue to have people who in theory are trained well but in practical terms are really not as fit for purpose as they should be. That will not be their fault; it will be our fault.

Amendment 26 very much echoes the thoughts behind Amendment 27. I particularly welcome in Amendment 27 the idea of having a 10-year plan. In fact, five years is short-term. It is better than what we have at the moment, but a 10-year plan is a really good idea, and I am sorry that I did not table that amendment. I saw it but thought that we would not want two amendments along the same lines.

On Amendment 26, Clause 85(1) of the Care Bill defines Health Education England’s responsibility as ensuring that,

“a sufficient number of persons with the skills and training to work as health care workers for the purposes of the health service is available to do so throughout England”.

Who could disagree with that? What a noble suggestion. While that would clearly include both healthcare support workers and nurses, the mandate, which was helpfully provided by the Minister before this debate, sets out a strategic national role in relation to medicine, dentistry and pharmacy in paragraph 5.2.6, and proposes a five-year workforce plan for “smaller specialties and professions” in paragraph 5.2.7, but provides little information on how the nursing workforce or the healthcare support workforce is to be undertaken and implemented. Does that not tell us all we need to know about what the priorities still are? While we have good words within the Bill, we do not have anything within the mandate that backs them up in a real sense. Midwives and health visitors suddenly appear, but I think that the commitment to having a comprehensive workforce under a five-year plan is worth really striving for.

Amendment 33 looks at the future guidance and standards for safe levels of staffing. I have a real problem with allocating numbers. When I was in another place, I remember arguing with the then Government about class sizes for years 1 and 2 in primary schools, where there had to be 30 children or fewer and the 31st child had to go somewhere else. You realise that, depending on the setting, you can do all sorts of different things. What we must not do is tie down the hands of high-quality management in being able to deploy staff in the most appropriate way. What matters is getting the mix of staff absolutely right. I hope that we will return to the question of staffing levels because it is fundamental but, frankly, we could go down the wrong road if we took it too seriously.

[Lord Touhig]

My Lords, time and again in this House the matter of training of health professionals so that they better understand how to support and care for people with autism has been debated. Here, I should declare an interest as a vice-president of the National Autistic Society. We know that key professionals such as GPs and community care assessors still do not have a good enough understanding of autism.

Amendment 24, about which the noble Lord, Lord Rix, has spoken and to which I have added my name in support, if taken on board by the Government would at least ensure that the Secretary of State would be required to consult vulnerable people, including those with autism, their carers and groups such as the National Autistic Society, Mencap and others on matters affecting education and training that will be provided by Health Education England.

Only one in three adults with autism in this country told the National Autistic Society in a survey that in their experience social workers have a good understanding of autism. There is a well established correlation between the professionals’ understanding of autism and the degree of identification of needs among adults in that local authority area with the condition. Autism training can help ensure that adults with autism are correctly identified, and qualify for the support they need.

I recently served on the autism and aging commission, chaired by the noble Baroness, Lady Greengross. Professor Francesca Happé gave evidence about the difficulties of picking up on autistic people’s needs. She said:

“This is a group that doesn’t self-present, doesn’t come and seek services, because of their difficulties of social interaction and communication and we absolutely owe it to them to go and find out what their needs are”.

For that reason, we need well trained people to support them.

The National Autistic Society’s excellent document, Push for Action: We Need to Turn the Autism Act into Action, made a very good case. It includes a very good case study by the mother of an adult with autism. Her name is Chloe, and she says:

“We got to the point where Peter couldn’t live at home, for his own and our safety. After moving around between people he knew and staying in a B&B, eventually he got a flat but he still doesn’t get any support. Social services don’t understand autism and how it affects him. They’re not asking the right questions. They say, ‘How are you?’, and he says, ‘I’m fine’, so they come back to me and say, ‘He’s fine, he doesn’t need any help’. But of course he says he’s fine at that point because he probably is at that point”.

He does not trust them, so he says he is fine in order to make them go away because he does not believe that they understand or are able to help him.

“He had a mental capacity assessment and they asked him about managing his money. He told them that he was saving money for a motorbike but he doesn’t have any money. He can’t manage his money. He gets into all sorts of trouble”.

Chloe concludes:

“I’ve given up asking for support. Me and my husband now do everything ourselves … Now we have no expectations of what ‘services’ should be providing”.

That is just one example of the lack of trained staff having an adverse impact on the life of an autistic person and their family.

I hope the Government will ensure that autism training is included in the core curricula for doctors, nurses and other clinicians, in accordance with the commitments under the Adult Autism Strategy. It is absolutely necessary that vulnerable groups, including people with autism, are consulted about priorities for training so that decision-makers become aware of the gaps in knowledge and understanding among health professionals.

Ultimately, the Government must tackle the issue by including autism training in the core curricula for doctors, nurses and other clinicians, as they committed to do in the 2010 Adult Autism Strategy. People with a learning disability and/or autism have the right to the same quality of healthcare as those without. I believe that Amendment 24 is a good step forward in achieving that.