Medicines and Medical Devices Bill

Lord Willis of Knaresborough Excerpts

2nd reading & 2nd reading (Hansard) & 2nd reading (Hansard): House of Lords
Wednesday 2nd September 2020 Lords Chamber

[Lord Willis of Knaresborough (LD) [V]]

My Lords, I suspect that much of my contribution will echo that of other noble Lords as this vital piece of legislation makes its way through our House. I say “vital” not simply because the overall market in pharma-medical devices and medical products is worth some £74 billion a year, but because without this legislation the chaos that derived from a no-deal Brexit would be catastrophic for patients and their families.

Let us be clear: this Bill is short on detail and accountability and places far too much power in the hands of the Secretary of State. The one overriding consequence is to deliver a system of regulation that is inferior to and more expensive than the one that currently exists. That is quite a triumph.

That said, there are elements of the Bill I welcome, particularly the registry of medical devices, and the greater enforcement powers over rogue operators, which are so clearly needed, following the excellent report by the noble Baroness, Lady Cumberlege—a report, incidentally, whose recommendations are embarrassingly absent from the Bill.

I welcome a more realistic approach to prescribing and extending the ability to prescribe to more healthcare professionals. What is not clear is how this is to be achieved. Will the Human Medicines Regulations 2012 be amended by a new clause in the Bill? Will a common framework for competency, based on the Royal Pharmaceutical Society’s competency framework, be included as a requirement for any new professional prescribing group? If not, where will its standards come from? Do the Government intend to address the issue of competency for those who do not prescribe but who administer drugs to patients? A safe administering practice is crucial, particularly in community settings, where often prescribing colleagues are in short supply.

Like many Peers, I am deeply concerned about aligning future regulatory systems. I welcome assurances given by Ministers, but we have to anticipate a situation where divergence of regulation may lead to the non-compliance of either our products or those of the EU and the US, our two major suppliers. Currently, the UK is a key player in the global regulation of medicines. Despite having only 3% of the global market, compared to the rest of Europe with 25%, we are able, through the MHRA, to punch well above our weight, as the noble Baroness, Lady Masham, so clearly stated. Three years ago, the UK was a rapporteur, assistant rapporteur or scientific advice co-ordinator for one in five EMA regulatory decisions—decisions that were accepted across the globe. The UK is a global player because of our excellent science but also because it has access, through the EMA, to the EU. Should we not retain the closest possible alignment with the EU, when the regulatory cost and impact burden might see huge problems for the UK medicines industry, with a rapid decline of market authorisations?

Finally, given the surge in personalised medicine which will drive so many novel treatments, I hope that the Bill can be amended to make it a requirement that, should a health professional offer a patient treatment using a fast-track drug, therapy or device with which they have had or will have a pecuniary interest, it must be declared. That is not the case today and it certainly should be. The report by the noble Baroness, Lady Cumberlege, looked particularly at areas such as fertilisation treatment, where there are some very important differences to be made. I look forward to further examination of the Bill in Committee but regret the fact that we have to have this at all.

Health Protection (Coronavirus, Restrictions) (Leicester) Regulations 2020

Lord Willis of Knaresborough Excerpts

Wednesday 29th July 2020 Lords Chamber

[Lord Willis of Knaresborough (LD) [V]]

My Lords, no doubt these regulations are technically competent, and no doubt they will be used as other communities—perhaps Oldham or Peterborough—become the latest virus hotspots. What they do not do is to put into legislation the tools that would give local health authorities and local councils the data to act more confidently and effectively to minimise disruption to lives, businesses and social structures in some of our poorest communities.

On 6 June, the Covid-19 Clinical Information Network recommended the co-ordination of all clinical and health records of patients admitted to hospital with suspected Covid. Has this happened in Leicester, and has it been published? Is this data available to those who require it, and why is there not a requirement to do so via this SI? On 22 June, the Scientific Pandemic Influenza Group on Modelling recommended linking health with clinical data and data from other systems, including employment and social security. Why has this recommendation not appeared in the SI? It would enable a much more vigorous examination of outbreaks, something Leicester has urgently needed, yet nothing has appeared in these regulations. Why is there no requirement for all healthcare workers, patients and care home residents in Leicester to be repeat-tested for Covid-19 during the lockdown? Why has universal serological testing not taken place to seek out antibody carriers in Leicester?

Research data will increasingly play a vital role in managing future outbreaks of Covid, and these regulations were an opportunity to grasp that. Sadly, we have missed that glorious opportunity.

[The Deputy Speaker (Lord Faulkner of Worcester) (Lab)]

The noble Lord, Lord Cormack, has withdrawn from this debate, so I call the noble Baroness, Lady Uddin.

Health Protection (Coronavirus, Restrictions) (No. 2) (England) Regulations 2020

Lord Willis of Knaresborough Excerpts

Friday 24th July 2020 Lords Chamber

[Lord Willis of Knaresborough (LD)]

My Lords, I understand the difficulty the Minister has in dealing with these regulations and have great sympathy for him, but I hope the Government note what has been said about having a better way of scrutinising them. The current system is clearly not fit for purpose and we need something different for September.

However, my key frustration is the almost total lack of published evidence to support any of the regulations at all. Those on 17 and 20 July still have no published evidence. Those coming out today, on face masks, and particularly those on visitors to care homes, have no evidence whatever. I ask the Minister to commit to publishing evidence for ministerial announcements alongside those announcements. This is clearly possible; he does not need to come here to do it. That gives confidence to the public and to those who want to adhere to the regulations.

Academic Health Science Centres

Lord Willis of Knaresborough Excerpts

Tuesday 2nd July 2019 Grand Committee

[Lord Willis of Knaresborough (LD)]

I, too, thank the noble Lord, Lord Butler, for initiating this debate. Given the number of people who will no doubt speak on behalf of different academic health science centres, the Committee should take it as read that I believe that they are all doing excellent work, because I want to explore one or two other areas.

On the need for a 21st-century research-led healthcare system, there is no political discord whatever—I think that we all agree on that, full stop. When the noble Lord, Lord Patel, managed to get the words “research led” on to the statute book during the passage of the Health and Social Care Act 2012, it was remarkable because it created a journey to which I think we all aspired.

There were some excellent signs. The early establishment of some academic health science centres during the years of the Labour Government was positive. In 2014, it was good to see the re-designation of six of them, five of them being in the “golden triangle” and the other in Manchester. I believed that was exciting but hoped it would pave the way for more. Why is there excellent research only in the south-east rather than elsewhere in the country? So far, that expansion has not transpired. If we simply go ahead and re-designate those already there, what will happen to my area, Yorkshire and the Humber? Are we saying that there are no initiatives worthy of designation in Yorkshire and the Humber or the north-east? Surely not. I hope that the Minister will take that on board.

My first plea in any reaccreditation exercise is to include areas that have a strong track record of collaboration between academia and research. In so doing, please use the opportunity to simplify structures that Peter Drucker once described as,

“the most complex in human history”.

Drucker was interesting, but it cannot be right to have differing governance, finance, clinical and political structures in each of the organisations, most with scant involvement of the people they serve. I have a great deal of time for Drucker but he had not looked at the rest of the health research landscape when he made his comments. As Professor Ovseiko argued in 2014, in a superb article on improving accountability through alignment, unless our model of competing structures for research, education, patient care and funding is radically streamlined we will not realise the huge potential for improved patient care that lies within our grasp.

The current landscape defies logical examination. We now have academic health science networks in every region with a remarkably similar mission to the AHSCs, except that they have a budget. Some have close ties with their AHSC, if it exists—not so in Yorkshire and the Humber—some do not. They should surely be brought together within the AHSN using its organisational structures, which are already there and are being paid for by the taxpayer. What about the collaborations for leadership in applied health research and care—the CLAHRCs—of which I am currently chairman, which are soon to be replaced by another set of organisations, the applied research collaborations, for which I am a prospective chairman? Again, some have close ties with a regional AHSN, some do not. For good measure, how do we ensure that our remarkable research effort actually benefits all our citizens, not simply the regions where the organisations currently are?

Finally, money is essential in this. We have a host of small elements of money. We need this to be properly funded. The whole nation needs to be involved and to take this wonderful opportunity forward.

Nursing and Midwifery (Amendment) Order 2018

Lord Willis of Knaresborough Excerpts

Monday 25th June 2018 Lords Chamber

[Baroness Thornton (Lab)]

I thank the Minister for his excellent explanation of this order, which provides the Nursing and Midwifery Council with the necessary legal powers to regulate the nursing associate profession. On these Benches, we will be supporting the order, and I thank the Nursing and Midwifery Council and the RCN for their excellent briefs.

We are ready to accept that the creation of nursing associates is a welcome addition to building capacity. Some of us who are long in the tooth—there may be one or two in the House today—will remember SRNs and SENs and wonder whether we have gone full circle to move forward. However, I accept that there is some urgency to get this on the statute book because, initially, 2,000 nursing associates were training at 35 Health Education England test sites, with a further 5,000 starts planned for this year. The first nursing associates will qualify to apply for registration with the NMC from January 2019, so I accept the urgency to implement this order.

The Minister says that the nursing associate role is a defined care role to act as a bridge between unregulated healthcare assistants and the registered nursing workforce. Now that that role has been created, we agree with the Royal College of Nursing that,

“there must be absolute clarity that the nursing associate … is not a separate profession, but a new role within the nursing family that works under the delegation of the Registered Nurse”.

It went on to ask for “urgent guidance” to be published on “the precise relationship between” nurse associates and registered nurses,

“in terms of delegation and accountability”.

I hope that the Minister has taken that on board.

It is important to recognise that this new role is not the answer to the huge workforce challenges faced by the NHS and the social care system. Last week when the Government announced their funding proposals for the NHS, and the creation of a 10-year plan, many noble Lords said—we agreed—that it would be meaningless if this does not cover healthcare workers and social care workers together, given their importance in the future of our healthcare and social care system. Given that Health Education England has had its budget slashed, that we have a huge decrease in healthcare workers from the European Union, and the soon-to-be-removed—I hope—ridiculous visa system for non-EU health workers, the fact is that more nurses are leaving the profession than joining it, and there is a demographic challenge in that one in three nurses is due to retire in the next decade. In that context there is a well-founded anxiety that nursing associates could be used as a substitute for registered nurses.

Also in that context, has this new role been thought through, or is it a quick response to nursing shortages, with unfilled nursing posts which, as we know, are at a record high? Linked to that, how do we ensure that this new role does not impact negatively on the social care workforce? The head of Health Education England has highlighted that problem.

The role of a nursing associate was created before this SI was even introduced. Has there been enough time to consider the standards and levels of training for nursing associates to be registered with the NMC? I have to say that I am comforted by two things. One is the comprehensive brief from the NMC which suggests that it is on top of this, and indeed the notes accompanying the amendment order itself. I want to raise two things with the Minister, which are on page 5 of the accompanying notes and concern the cost-benefit impact analysis and the regulation of the nursing associates. Two risks are identified:

“First, there is a financial risk that the agreed initial set up costs escalate beyond those currently agreed with NMC. Second, the unquantified costs mentioned above relating to setting up and/or amending existing nursing associate courses as well as the accreditation of education providers”.


Those risks need to be mitigated before this moves forward in an orderly fashion. Finally, I think that there is provision in the order to take account of European Economic Area nursing associates, but I understand that this is not a uniform description or role that fits the narrative across the board. Will the Minister also comment on that?

[Lord Willis of Knaresborough (LD)]

My Lords, I rise from the second Bench—I am not quite trusted to be on the front yet—

[A noble Lord]

Oh!

[Lord Willis of Knaresborough]

Thank you for your commiseration. I support the Nursing and Midwifery (Amendment) Order 2018. I do so with a very personal endorsement and declare my interest as an honorary fellow of the RCN; as a consultant to HEE and the NMC, with which I have been working on these regulations; and as the author of the Shape of Caring report, which is the origin of the nursing associate proposal. I recognise the work of two people in particular. The noble Baroness, Lady Thornton, kindly and quite rightly mentioned the NMC and the work that Jackie Smith has done to bring this through the process. The NMC was presented with two big issues: the new standards for nurses and those for nursing associates, which it took on at the request of the Government. She has led both those processes admirably. Although she is leaving her post next month, this House, and the profession, owe her a great deal of gratitude for what she has done.

I also want to mention and put on record Samantha Donohue, a registered nurse currently studying for a PhD. Her job has been to deal with all the pilot sites, the 8,000 applicants and the 2,023 colleagues who have started training. This has been a Herculean job; at every stage there has been some objection to overcome. I hope that, when he responds to this debate, the Minister will recognise that at times we have in our midst people who do fantastic jobs and do not require to be told how to do them by people elsewhere: they just get on and do it.

The noble Baroness, Lady Thornton, suggested that this matter has been rushed through. I understand that the regulation has followed the start of the pilots but, as independent chair of the Shape of Caring review, it took me over two years’ work to produce the 34 recommendations that led to this process and the recognition that nursing standards needed to change. Quite often, we look at the healthcare workforce in silos, instead of looking at it as a complete, interdependent ecosystem. There are also silos within silos in every section of the healthcare workforce—medics, consultants, physios, care workers or registered nurses—each of which fights for its space. When I was doing this work, particularly when I visited the United States and looked at the Magnet hospital set-up, I was drawn to the fact that nurses are right at the centre of and pivotal to a 21st-century healthcare system. Unless you put them at the centre, the rest of it will not work as smoothly as it should.

I totally support the move of the workforce to graduate status, but we have not fully realised the potential of a graduate nurse workforce. This role frees the registered nurses for the leadership in care that they have been prevented from doing because they are bogged down—I do not mean that in a disrespectful way—by the host of other tasks they have to do. The idea of being able to lead this care while safely delegating is at the heart of the report’s recommendations. Both Robert Francis, in the Mid Staffs report, and the noble Baroness, Lady Cavendish, who produced the superb report on care workers, recognised that unless those two groups of workers—the noble Baroness, Lady Thornton, mentioned them, too—are properly trained and get a recognition within the training organisation, you cannot safely delegate to people when you cannot rely on their having the skills to carry out those tasks. The nursing associate fills that gap. It liberates the registered nurse and at the same time makes sure that there is safe regulation. The establishment of the nursing associate is not, as the Minister rightly says, a substitute for a registered nurse; nor is it an investment in their long-term career. It is a point of registration—that is all. This is not the time for this debate, but unless we make provision for ongoing professional development of the whole of the nursing and care workforce, we will not get the benefit from either the nursing associate or the new role of the registered nurse.

I shall ask the Minister a number of brief questions. The first is about the apprenticeship route. I support that route, as I think most Members of the House do, and the apprenticeship levy is an obvious route for employers to take when expanding the nursing associate workforce. There will be a temptation, however, which the apprenticeship route encourages, to tailor the experience of individuals to the needs of the organisation, rather than to recognise that huge strands are working through this role which need to be applied elsewhere. We must not fall into the trap of having people who can work in only one organisation. They need to be able to develop skills that are transferable to wherever they are expected to work. Will the Minister therefore confirm that apprenticeships, in common with other routes into nursing, must be NMC-approved programmes and must be delivered by NMC-approved providers? Will he also confirm that the requirement in the pre-regulation apprenticeship standard that programmes are delivered by NMC-approved AEIs that deliver nurse education will continue? Will he also confirm that any change to those processes will be reported to Parliament for debate?

My second question is on overseas applications. How we deal with that will be a real challenge as we move forward past Brexit. Will the Minister confirm that such applicants will not be eligible for the nursing association register unless they have comparable qualifications from a higher education establishment and have passed a competence test set out by the NMC? I hope the House will appreciate that I am trying to guard against a second class of nurses. We want people whose standards are set and we want to maintain them, wherever they come from. That is important.

Thirdly, on Scotland, Wales and Northern Ireland, I was disappointed—like I think many people in the House—that they are not part of this process. The NMC regulates across the United Kingdom, not just in England, and it is a sad state of affairs that we now have this separation between England and the other three countries. If the countries decide to introduce a similar post, will they be able to instruct the NMC separately to regulate it, or can they introduce a post with identical requirements—let us call it a nursing assistant—without regulation? It would be wrong if we found ourselves within the United Kingdom having different regulatory or non-regulatory systems around the same post in different jurisdictions.

There has been much concern about the new nursing associate role being a role in its own right or an adjunct to a registered nurse. The issue is clarified in paragraph 7.20 of the Explanatory Notes, but I think it will remain an issue. Therefore, will the Minister confirm that nursing associates will not simply be the handmaidens of registered nurses? That cannot be the case. This is part of the nursing profession, full stop. It is part of that family, with a distinct role, primarily to underpin the work of the registered nurse but also to carry out functions in its own right wherever needed. A classic example is nursing homes. At the moment, a host of relatively poorly qualified people are working in nursing homes, often under the direction of just one registered nurse. At night, that provision is often only at the end of the phone. We really must not have that. We must simply say that we want people we can rely on, who will have the confidence of patients and their families.

With those comments in mind, I say to the Minister that in 10 years’ time there will be some 70,000 nursing associates registered and working in the system. What a present it is that, on the 70th anniversary of the NHS, we are establishing a new workforce to supplement and support the existing workforce to deliver an even better NHS.

--- Later in debate ---

The same argument applies to apprenticeships. Who is going to pay the fees? Is it the local employing body? If that is the case, there will be a lot of encouragement for local trusts not to have NAs, because they will have to pay for them. Why are the figures related to that?

[Lord Willis of Knaresborough]

Perhaps I might help. Some of the thinking behind the funding model, in particular for apprenticeships, relates to the levy. It will not apply to very small trusts, but most large trusts have a 0.5% employment levy, and to apply that through the apprenticeship route seems very logical. Whether it will work is a different matter, but that is the logic.

[Lord Clark of Windermere]

I am very grateful for that—and I understand that many trusts contribute to the levy. Perhaps the Minister could give us an indication of what the breakdown will be between the conventional course and the apprenticeship course for nurse associates. That would be helpful, because one has to bear in mind that the cost to a registered nurse undergraduate is £9,000 a year. That is what they have to pay—which means that they will pay £27,000 to get their qualification.

We need to continue at a high level. As the Minister said, we have increased the number of nurses in training; I found that very encouraging. He is absolutely correct. But why should somebody who wants to become a registered nurse spend £27,000 over three years when they could do a conventional NA qualification for two years at no cost, then do another year to become a fully qualified registered nurse? It just does not make sense. The Government have to look at the funding of nurse support training as a whole. I hope that they do so.

I felt that it was right and proper to raise these difficulties as they have not been raised elsewhere because, as I said, many of the consultees have other interests in putting forward their points of view.

Long-term Plan for the NHS

Lord Willis of Knaresborough Excerpts

Tuesday 19th June 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord mentions the figure of 4%. I have looked at a number of think tank reports and their assumptions on what is required. They make some very cautious assumptions of the productivity improvements that the NHS is making, based on historical performance. The improvements in productivity over the last five years are very healthy—in fact, in the last year the NHS became more productive at a rate of 1.8%. If you add that to the 3.4%, that gives an increase of more than 5% in terms of bang for your buck. It is incumbent on us during this process not only to put in more money but to make sure that we are driving those productivity gains that we have seen in the last five years. If that then gives a 5% effective increase in funding, that is what we will need to deal with the long-term pressures that the noble Lord has quite rightly highlighted.

On the three questions, there is an explicit commitment to deliver this workforce strategy that the NHS comes up with as part of its plan. On the extra costs of social care, we clearly need a social care settlement that delivers the funding for those rather than their being covered by the NHS. That is what we mean about the commitment not to create extra pressures. As I have said, the funding will come from three sources—whatever the mix, the funding will be there.

[Lord Willis of Knaresborough (LD)]

Will the Minister accept that in terms of productivity, one of the issues that is holding us back in developing things at speed is the overregulation of the whole of the health system? We have two systems regulators and seven professional regulators; we were promised in 2014 that there would be legislation to simplify the regulatory system. Can the noble Lord assure the House that we will have a bonfire of regulations and put the right regulations in place to move this agenda forward?

[Lord O'Shaughnessy]

The noble Lord speaks with great insight and makes a very important point. There is broad agreement on the need to simplify the structure of the health system but there has not to date been broad agreement on how we should do so. We are expecting in the next few months to explore the potential for the kind of streamlining that he is talking about. I hope that that can be done as a collaborative effort and, if it comes to primary legislation, that we can deliver it as a collaborative effort too.

Education (Student Support) (Amendment) (No. 2) Regulations 2018

Lord Willis of Knaresborough Excerpts

Monday 21st May 2018 Lords Chamber

[Lord Puttnam (Lab)]

My Lords, I will probably not be quite as brief as the noble Baroness, Lady Garden, but I support the Motion of my noble friend Lord Hunt. In doing so, I hope to help the Minister with some experiences from the past, which I think are very germane.

My noble friend Lord Hunt and I entered this House on exactly the same day: 5 November 1997. He came as someone with great authority and experience in the National Health Service; I came from a terribly different world, with the specific job of working for the right honourable David Blunkett—now the noble Lord, Lord Blunkett, then the Secretary of State for Education. We had a crisis in teaching and with teachers. I commend to the House the front page of the Times Educational Supplement from 6 April. It states:

“Missing: 47,000 secondary teachers. In a system already struggling to fill the gaps, some are thinking the unthinkable: is it time for teaching without teachers?”


I would add this: is it time for nursing without nurses?

The situation is very serious because any possibility that the Minister and his department have of resolving the problem depends entirely on the pipeline supplied by the teaching profession. That has a time factor attached to it, which is very important. It took the Blair Government—I worked constantly at the department for education—six years to get back to equilibrium after the teaching crisis. We were short of around 47,000 teachers—ironically, almost exactly the same number that we are short of today.

Here is the problem: a demographic bulge will hit us in 2024. At that point, we will be short of something close to 50,000 secondary teachers. It is totally predictable; we can see it coming. It happens to be coming at a time when the number of graduates entering the profession is, necessarily, quite light because of an inverted demographic. I am sure that the noble Lord, Lord Willis of Knaresborough, will understand and attest to the figures I am giving. We had an enormous problem. This Government have an enormous problem, and the less they solve their educational pipeline problem, by ensuring that there are enough teachers in the system, the worse the nursing problem will get.

I commend the past to the Minister. We learned a powerful lesson between 1997 and 2003. Unless the Minister wants to revisit a similar lesson in the National Health Service, he must address this issue now.

[Lord Willis of Knaresborough (LD)]

My Lords, I thank the noble Lord, Lord Puttnam, for reminding us of those days, which were both terrifying—I say that as an ex-educationalist—and exciting. Meeting the challenge, based on an evidence base, enables you to move forward. I declare an interest, having worked for the past few years for Health Education England since its formation as a non-departmental body, following the 2012 Act.

What I find terribly sad about this SI is the lack of evidence behind the move. I do not know, and I suspect very few people in this House know, whether the move to an all-graduate profession—treating nursing graduates the same as teaching graduates or graduates going into law or other professions—should be done on a loan system. There is an argument for that, but in reality, we have absolutely no evidence to demonstrate that it will be effective, particularly at undergraduate level. Like many Members of the House, I look forward to the student funding review, because at least we will get that evidence base, which will be put before both Houses.

I find what I think is behind this deeply disappointing. Your Lordships spent many months debating the Health and Social Care Act 2012. There were a lot of fierce arguments. One of the reasons why the then coalition Government put forward the proposals was to take many of the decisions, particularly about staffing and education, out of the political arena and give them to an NDPB, to allow them to plan ahead. Health Education England was created for that very purpose. This is doing the exact opposite. It is pointless having an organisation which is there to plan a workforce and then taking away the means by which it can generate that workforce, be it at undergraduate or postgraduate level. It saddens me that after some of the excellent things that have been introduced—I declare an interest as having been involved with the nursing associate proposal—the belief is still peddled that this is somehow substitution. It should not be, it is not and it must not be a substitution. The noble Lord, Lord Hunt, is absolutely right to make that point: we do not want to move back to a lower quality simply to produce more people.

Will the Minister give us an idea of the quality, particularly at undergraduate level? I am sure that he will say that while we might not have as many applicants, we still have as many actual posts and that the quality of people applying for those posts is going up. I can find no evidence at all in the HESA survey that that is actually happening. If it is, I will celebrate it, and I am sure the Minister will tell us. The issue I want to raise—it is why I have spoken in this debate—concerns one of the great areas of weakness at the moment, and that is our ability to recruit and retain mental health nurses. This is a massive issue, and not simply for traditional reasons but because the demographics and the epidemiology show that ever more of us who, like your Lordships, have an average age of 70-plus are likely to have a mental health problem as part of their comorbidities as they get older. Few of us can deny that.

I am working at the moment at how we can provide the mental health workforce in 10 or 15 years’ time. I look around at where there is a stream of potential workers who could come in, and frankly it is at postgraduate level, using psychology graduates. I can tell the House that over the last three years, 49,466 psychology graduates have come out of our universities, yet we have a dire shortage of postgraduate mental health nurses. Instead of proposing, as my work does, that we really target these people to try to fill this gap in relatively quick time, this SI is saying that that is no longer possible, that these people with debts already from their university days—their undergraduate days—will now face having to fund work in a specialist area. Will the Government look seriously not just at narrow shortages but at wholesale shortages, which we certainly have in mental health nursing? Can we find a better way of attracting and retaining these people?

I finish with three brief questions. We are going to get, through the NHS and indeed through private sector organisations, 0.5% of their payroll being spent on the apprenticeship levy. I ask the Minister whether trusts and private sector organisations, particularly those in adult social care, will be able to use part of that levy to create in-house bursaries to support the development of staff. As yet we have not talked about the role of other sectors in bringing these people through. Will that be possible?

Secondly, if the Minister says, “Ah, no, BEIS says that you can use this money only if it is for apprenticeships”, are we able to rebadge postgraduate work in nursing, in the different fields, through the levy to provide the bursary—and, of course, fee remission—as a result of that route? There is a big pool of money coming in here, which could be used much more effectively.

Thirdly and finally, I ask the Minister, in trying to solve this conundrum, to make an assurance to this House that it is quality that we want and quality we must give to the people of the UK—particularly the people of England, to which this SI applies—rather than quick fixes in other ways, which I am sure will come down the track if we do not resolve this matter now.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, I congratulate the noble Lord, Lord Hunt, on securing this debate, and express my gratitude to all noble Lords for speaking. I always welcome the high profile that issues relating to NHS staffing receive in this House and I am always pleased to debate our approach with noble Lords, who I know are motivated by a desire to protect and promote our world-class NHS, and bring both wisdom and expertise.

I will start by explaining the overall rationale behind the reforms that the Government are making. The decision to remove bursaries for nursing, midwifery and allied health profession students and to provide them with access to the student loan system was taken by the Department of Health—as was—in the 2015 spending review. One reason for that was that this group of students had access to less money through the NHS bursary system than students in the student loan system. By moving to the loan system, these students now typically receive a 25% increase in the financial resources available to them for living costs during their time at university.

[Lord Willis of Knaresborough]

Before the Minister goes one second further, will he confirm that the bursary money was free money? They did not have to pay that back. Now they have to pay back the whole loan.

[Lord O’Shaughnessy]

If the noble Lord will let me finish, I will get to that point. Like other graduates, student nurses will be required to repay these government-funded loans only once they are in employment and earning. It is important to state that the student loan repayment terms are progressive. From April 2018, individuals will make their contribution to the system only when they are earning more than £25,000. Monthly repayments are linked to income, not to interest rates or the amount borrowed, and the outstanding debt is written off after 30 years.

I am not the Education Minister in this House, although I seem to be covering this topic not only tonight but in other forums, but it is important to underline that the reason this system was introduced into this country by a Labour Government, reaffirmed by a coalition Government and continued by a Conservative Government, is that it means that the best-earning graduates, instead of having their fees entirely paid by taxpayers, including people who have never gone to university, make a contribution to the costs incurred, whereas those who are lower-earning through their lives, including those who will perhaps never earn more than £25,000, will make no contribution. That is a more progressive system of funding than one in which everybody gets it for free, no matter how much money they make in their life.

As I said, these reforms give student nurses access to more financial support, albeit they have to pay that back if they can afford to do so later in life. It also provides a level playing field with other students. But perhaps most importantly of all, these actions released about £1 billion of funding to be reinvested in the NHS front line. As a consequence, Health Education England plans to increase the number of fully funded nurse training places by 25% from September 2018. It is important to stress that Health Education England has made that decision as an independent body to meet the need for more nurses that we all agree is there.

As the noble Lord, Lord Hunt, pointed out, this equates to around 5,000 more places each year—a major and welcome boost to our much-admired nursing workforce. My background is largely in education and I assure the noble Lord, Lord Puttnam, that we understand the urgency of this task and the parallels with education that he mentioned.

NHS: Nurse Retention

Lord Willis of Knaresborough Excerpts

Wednesday 17th January 2018 Lords Chamber

[Lord O’Shaughnessy]

We know that we have a growing ageing population—I do not doubt that. We have been increasing real-terms funding for the NHS, which is going on more staff. Nurse numbers have increased and I should point out that there are more doctors and ambulance staff. There have been about 40,000 more clinical staff in general in the NHS over the past few years and more to come in the future.

[Lord Willis of Knaresborough (LD)]

Does the Minister accept that roughly 10% of our nursing workforce has left the profession this year? Many of them are new recruits or not long into their careers. It takes about £80,000 to train a nurse. Any employer with any sense would want, first, to retain them and, secondly, when they leave, to know why they have left, where they have gone and how to get them back. What are we doing to track people who leave and what are we doing to attract them back?

Nursing and Midwifery (Amendment) Order 2017

Lord Willis of Knaresborough Excerpts

Tuesday 28th February 2017 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I thank the Minister for introducing the order.

It is fair to say that we debate midwifery regulation at a time of great challenge for the profession. I was looking recently at the fifth State of Maternity Services Report, produced by the Royal College of Midwives, which shows so clearly that we are in the eye of a perfect storm: the number of births is going up; there are fewer births to younger women and more to older women, which puts extra pressure on services; and we need more midwives.

We also need more midwives because of the age profile of the profession and the attrition rate of newly qualified midwives. One in three midwives are in their 50s and 60s. Even though, as the Minister has said, the number of training places is going up, the RCM estimates that the net annual increase at the moment is only about 100 midwives per annum. The RCM argues that, to deal with this, the NHS needs to do much more to retain existing staff and ensure that newly qualified midwives are employed quickly.

I very much share the Minister’s view that it is important we have an effective regulatory system alongside effective supervision of the profession, with clear and visible leadership at local, regional and national levels, but this is at the heart of my concerns about the order. The Minister explained very well the background to the order and the various reviews emanating from the serious incidents in Morecambe Bay. The NMC subsequently commissioned advice from the King’s Fund, which took as its basis that midwifery is regulated differently from other healthcare professions. The King’s Fund also undertook a review, to which information provided by the overseeing Professional Standards Authority cited,

“a lack of evidence to suggest that the risks posed by contemporary midwifery require an additional tier of regulation”—

that is, the supervisors—

“bringing into question the proportionality of the current system when compared to that operating for other professions”.

The PSA also stated that,

“the imposition of regulatory sanctions or prohibitions by one midwife on another without lay scrutiny is counter to principles of good regulation in the post-Shipman era”.

As the Minister has said, the core recommendation arising from that work of the King’s Fund was that,

“The NMC as the health care professional regulator should have direct responsibility and accountability solely for the core functions of regulation. The legislation pertaining to the NMC should be revised to reflect this. This means that the additional layer of regulation currently in place for midwives and the extended role for the NMC over statutory supervision should end”.


As we have heard, the NMC has accepted that core recommendation, which is reflected in the order before us.

I understand clearly the logic behind the recommendation and the order that we have tonight, but I think it is worth looking in detail at the King’s Fund report. It acknowledged that, if you removed the supervisory role and restricted the role of the NMC to purely that of a regulator—which I do not disagree with—you would leave a gap. As the King’s Fund said,

“While clearly valued and of benefit to midwives, the functions of support and development, leadership of the profession and strategic clinical leadership are not the role of the regulator. We believe that others in the health care system should take on responsibility for ensuring these functions continue”.


The report laid out a number of options and acknowledged that this was not guaranteed. It therefore recommended that the Department of Health,

“should consider how best to ensure access to ongoing supervision and support for midwives … Organisations providing maternity care should consider how they will continue to provide access for service users to discuss aspects of their care … NHS England … should assure themselves that they have adequate facility for accessing strategic input from the midwifery profession into the development of maternity services”.

Essentially, the point of my regret Motion is to ask the Minister to spell out exactly what progress is being made—

[Lord Willis of Knaresborough (LD)]

The noble Lord has raised an incredibly important point. Would he accept that the department, and indeed NHS England, together with the regulator, have moved very quickly to have the chief nursing officers from the four countries charged with the responsibilities, which quite rightly they should have, for actually putting in place adequate supervisory arrangements in order to support the midwives? Does he not feel that that is sufficient? If not, what else could be done?

[Lord Hunt of Kings Heath]

I am very grateful to the noble Lord for his intervention. I fully accept the point he raises. The noble Lord knows a very great deal about nursing and midwifery, and has done some very valuable work in this area, but he mentioned the word “nursing”. He will know that there is an issue about how midwifery leadership is undertaken under the banner of nurses. That is really what I want to come to, but I think his point is very valid.

I am not suggesting that the Government—essentially, we are talking about four government departments—have not looked into this issue, but there are some issues about the visibility of professional leadership of the midwifery profession which I worry about. We know that midwives are subsumed under nursing leadership, and that has some consequences when it comes to priorities and resources. It is also worth saying to the noble Lord that, of course, often these directors can be described as directors of nursing and midwifery, but to get to a director level in the NHS, even at NHS trust level, midwives have to become directors of nursing and therefore they need a nursing qualification. My understanding is that only 30% of midwives are also nurses, so there is almost a glass ceiling for many members of the midwifery profession.

Why am I concerned about this? It is very simply that, given the huge pressures on midwifery at the moment, I worry that, when it comes to decisions being made nationally, either in the Department of Health or other health departments, or in NHS England or in the regional offices of NHS England, or locally on the boards of NHS trusts, with the best will in the world the midwifery voice is often not heard. As we see pressure coming on midwifery services, it is a worry that at board level, for example, there are few instances where the head of midwifery reports directly to the board, so the board does not always hear the concerns of the midwifery profession.

[Lord Willis of Knaresborough]

I enjoy this better than listening to great long tirades. Is the noble Lord not pointing to a system failure in our health service? Is he not falling into the trap of saying that, unless you have a protected silo, you cannot have an adequate voice? Surely, given his own thinking in Birmingham, which has been quite outstanding, and given what is happening in Manchester, we are looking at health economies where we are putting together groups of professionals working as teams, rather than perpetuating the idea that, unless we have a silo, we cannot move forward.

[Lord Hunt of Kings Heath]

My Lords, I understand where the noble Lord is coming from. I would never want to propose a situation of a silo, but there are instances where it is necessary to give—I do not think that “protection” is exactly the word—some kind of underlining to the importance of a particular profession. The noble Baroness, Lady Cumberlege, is here, and it seems to me that the fact that she had to undertake a review recently is a visible sign of the problems that we have had in getting midwifery issues to the top of the table. I am not seeking to create a whole hierarchy of new directors at a cost of money and to silo it, but I think that we have some problems at the moment.

This issue was raised in the other place when the order was debated there. I actually think there is a case for there to be a chief midwifery officer at government level. In the other place, the Minister said that the Government consider that,

“the chief nursing officer is the professional lead for both nursing and midwifery and we intend that to continue. That role is supported by the head of maternity in NHS England, which will continue to be the case. … There will be a regional maternity lead and a deputy regional maternity lead in each of the four NHS England regions”.—[Official Report, Commons, Delegated Legislation Committee, 22/2/17; cols. 9-10.]

I must say that I do not like the term “maternity lead”, as it seems to understate and undermine the position. I know that you cannot say that everything is in the title, but “maternity lead” to me means a lower status—it is quite clear to me that you use “maternity lead” to indicate a lower status.

Let me be clear that the current head of midwifery in NHS England is a distinguished and highly respected midwife—there is no question about that—but I think that there is a problem. What does “head of midwifery” mean? Why do we not use the word “director”? There is an issue about authority and status. At the end of the day, as I understand it, the head of midwifery is the head of the profession in England, and I think that NHS England should recognise that in that person’s title and position.

It is very important that midwives as a whole look to the chief midwife for that essential professional leadership. It is clear from what the NMC has said, and from the order before us, that the NMC cannot provide that professional leadership. It is there to regulate, so we need strong professional leadership. I hope that the Minister will give this some further consideration. I am not seeking to create a whole new edifice; I am concerned about the voice of midwifery not being heard at the highest level.

That brings me to the proposed abolition of the midwifery committee. Again, I am the last person to believe that, if you have a committee, everything is well. Of course, I understand entirely why the NMC does not like the statutory midwifery committee. I completely get that; no chief executive of any body ever likes to have a statutory committee, particularly if the other bits of the area that it regulates do not have one. We all understand that, but you have to look at the fact that the NMC currently has 640,000 nurses on its register and 40,000 midwives. Inevitably, issues to do with nursing are bound to dominate the NMC consideration. So the benefit of having a statutory committee is again to give some kind of protection and recognition that midwifery needs to have some consideration within this very large regulatory body.

As a result of discussions, for which I am grateful, the NMC has given various assurances about the strategic midwifery panel and the number of advisers that will be appointed. Can the Minister ensure that Parliament is kept informed of the work of the NMC and, in particular, about how it will ensure that it is fully apprised of midwifery matters by the new arrangements? He said earlier that the NMC would keep these matters under review—and I think that he referred to the new disciplinary procedures—but I took that to mean these arrangements in general. “Under review” falls within governance and quango-land; it is not really a high status. Could he ensure that, at the very least, the NMC reports to Parliament on a regular basis on how it ensures that midwifery issues are fully heard by the council?

In conclusion, in moving this amendment I do not seek to criticise the NMC. I believe that the current chief executive inherited a mammoth challenge. I have been impressed by the progress that she has made, but the distinctive role of midwifery should be recognised, particularly at a time of extreme pressure on the profession. It is important that we do not dissipate its voice. I would welcome some reassurance from the Minister. I beg to move.

--- Later in debate ---

Finally, I ask my noble friend to agree that there is a need for a senior midwifery voice within the UK Government. As has been said, we have a superb leader in NHS England on midwifery care, but that person needs a higher status. That person should be on the same level as the Chief Nursing Officer, because they are looking at different aspects. Can my noble friend consider having a chief midwifery officer at the national level, with directors of midwifery within the NHS England regional teams? We need that leadership. Over the years it has been much diminished, as the noble Lord, Lord Hunt, explained very well. We very much admire the lead maternity person in NHS England but they need to be called a “director”. She or he needs a higher status, and I do not think that such a request is impossible to respond to.

[Lord Willis of Knaresborough]

My Lords, at the beginning of this debate I decided not to say anything. I have been stung into action but I will be incredibly brief. First, I thank the noble Lord, Lord Hunt, for tabling his amendment to the Motion. Although I am very supportive of the order, he has again demonstrated the need to debate these orders and to get the views of Members of your Lordships’ House who have vast experience in these areas. The noble Baroness, Lady Cumberlege, has again demonstrated the breadth of her experience and has brought it to bear.

I should declare my interests as a consultant to the NMC and as a fellow of the Royal College of Nursing—an honorary one because I have never been a nurse and have never been on the register. People would not trust me in that way. I should also put on the record that I am huge admirer of the midwifery profession. My daughter has recently had two caesarean sections in different parts of the country. One location, which I shall not name, was incredibly disappointing and demonstrated some of the real issues that have to be addressed. That is where my passion for a more integrated service has come from.

The other birth took place last year in York, which has an integrated and mother-led maternity service—exactly what my noble friend Lady Walmsley and the noble Baroness referred to. There, the mother is not a recipient on behalf of others but leads the whole process—everything from pain management to enhanced recovery. All of this demonstrates what is in the noble Baroness’s report. Things should be looked at from the mother’s point of view and built up from there.

Again, I would not wish my silo comments to be misunderstood but I am desperately anxious that the role of the midwife should in many ways go back to its origins. This legislation goes back over a century, but in those days the midwife was not simply someone who ensured a safe birth; she was instrumental in dealing with the family within the community. I feel that we miss a trick when we do not use the phenomenal expertise within the midwifery profession to become leaders in carrying forward the Government’s drive—rightly, in my view—towards a community, population-based health economy. Midwives could fulfil that role.

There are two issues relating to the order, and I want to stick to those rather than deal with some of the other issues that have been raised. The first is fitness to practise, the importance of which has been somewhat overlooked compared with the removal of the committee. Fitness to practise is a huge issue both for midwives and for the nursing profession. Some £48 million a year of nurses’ and midwives’ own money is spent on this process. People often wait five years for a resolution. Their career is wrecked, they cannot go back to practise and we lose them. All that needs to be addressed. I applaud the Government for listening to the concerns of the Nursing and Midwifery Council and for bringing in a fitness-to-practise process. That will at least speed matters up and get an early resolution.

Quite rightly, questions have been raised about the way in which affirmative resolutions come about, whether they should be in the order or in guidance, and whether the guidance should be statutory. These are things for the Minister to work out with his colleagues, and I applaud those questions. It is very important that we have a system which is speedy, fair and appropriate.

The second issue with the order is the separation of the role of regulation from professional interest. I cannot believe that anyone believes that that is not the right thing to do. With independent regulators of healthcare systems—whether they relate to dentists, doctors, nurses or midwives—the professional interest should be separated from the regulatory interest. That is what this order tries to do. Rightly, the noble Baroness, Lady Cumberlege, and the noble Lord, Lord Hunt, asked whether, by separating them, you lose something or gain something. I believe that we gain something enormous by having a regulator who can concentrate and where everybody knows where the regulatory burden lies and there is a clear responsibility to deal with it. The reports on Morecambe Bay show that that was all fudged, with one blaming the other. I think that we must try to move away from that.

The whole issue of supervision worries me as much as it does other Members of the House. We cannot simply say that, by putting it with the four lead nurses, who are responsible for nursing and midwifery, the problem is solved. We know full well that that is not the case. For instance, they do not have a resource to be able to deliver that service across the four countries. I hope that the Minister, when he replies, will say what plans the Government have to actually enforce and indeed to support the four CNOs, or Chief Nursing Officers—and midwifery officers, we should call them—rather than simply leave them to get on with it.

This order is going in the right direction. Sadly, it misses out one thing—I thought the Minister might mention it in his opening statement—which is that the department has said on a number of occasions that this order has nothing to do with the scope of midwifery practice. The noble Baroness, Lady Cumberlege, quite rightly said that we have to have someone who sets the standards for midwifery in the future, and it has to be the NMC. I totally agree with her. But, quite frankly, simply creating more of the same is not the answer as we move forward. You cannot have the models that she described in her excellent report without having far greater flexibility within the system than we have now.

When the NMC looks at the scope of midwifery practice in setting new standards—as I am sure it will—I hope that it will look at how we can put midwifery rightfully in place right at the heart of our care system and make sure that the sort of standards that we have lived by for the past century are enhanced and that we can be proud of them as we move forward. I applaud the Minister for bringing this forward and I am wholly supportive of it, although my colleague has a few reservations.

Nurses: Training

Lord Willis of Knaresborough Excerpts

Tuesday 22nd November 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, as my noble friend probably knows, we are introducing nursing associates into the NHS. There are a thousand in place today, and a further thousand will come in next year. That is the bridge between healthcare support workers and degree-trained nurses. We recognise that there should be another route into nursing—not just the university route, but a more traditional apprenticeship route.

[Lord Willis of Knaresborough (LD)]

My Lords—

[Baroness Watkins of Tavistock (CB)]

My Lords—

--- Later in debate ---

[Lord Prior of Brampton]

My Lords, the best estimate of Health Education England is that, making reasonable assumptions about the attrition rate of students and the retention of existing nurses, by 2020 we will have 40,000 more registered nurses working in the NHS than we do today.

[Lord Willis of Knaresborough]

Will the Minister accept—at last—that simply providing more training places and increasing the number going through both the associate route and the graduate apprentice route is only part of the solution? At the moment we are losing a huge number of nurses, with roughly 10% of our graduate registered nurses going through attrition each year, as the Minister accepted. Two years ago, the Secretary of State gave a mandate to reduce attrition by 50%. Can the Minister tell the House how successful that has been, and can he put in the Library the figures showing how many fewer people are leaving the profession simply because we are not looking after, nurturing or caring for our existing workforce?

[Lord Prior of Brampton]

I think that there is some confusion here. The attrition rate that I was referring to was the one in nursing schools, which on average has been running at about 9.5%. Attrition among the regular workforce, which I think the noble Lord is referring to, is clearly a huge issue for us. Interestingly, we have set up a return-to-practice initiative, which has brought a thousand nurses back into the profession at a cost of £2,000 per person. That is extremely good value if we can persuade people to come back into the service. The noble Lord is absolutely right: people retiring early or leaving early is potentially very damaging for the service. However, I reiterate that the figure of an extra 40,000 nurses in the NHS by 2020 is arrived at after making reasonable assumptions about the level of attrition among the existing workforce.