Care Bill [HL]

Debate between Lord Willis of Knaresborough and Baroness Emerton

Tuesday 4th June 2013 Lords Chamber

[Lord Willis of Knaresborough]

My Lords, in the Second Reading debate on the Health and Social Care Bill, now an Act, I made the point that while we were talking about structures until the cows came home, the things that really mattered were the education and training of the staff within the NHS and the research element that gave those staff the very best tools in order to be able to care for patients and have good patient outcomes.

I compliment not only my noble friend, but the whole House, and indeed the whole Parliament, on the way in which it got behind the proposal in that Bill which is now in this one to create Health Education England as a way forward. The appointment of Sir Keith Pearson, who knows the supply side very well and has the ability to bring people together to listen to what he has to say and to be able to develop Health Education England as a real force for good, is quite outstanding. My worry is that we will start to bind the hands of Sir Keith and Health Education England, and we must not do that. What is required now is an organisation that is given sufficient flexibility and power to be able to grasp the key issues that are facing the NHS and to move forward.

I support very strongly the amendment in the names of the noble Lords, Lord Turnberg and Lord Patel, to include on the board people with relevant expertise. I am pleased that the noble Lord did not go on to say exactly who should be on that board, because I believe that that would be a step too far. But to have somebody with a real background in training, education and medical research would bring great strengths to the board.

I also support Amendment 3 in the name of the noble Lord, Lord Hunt. Indeed, I support virtually all the amendments tabled by the noble Lord and compliment him on the way in which he introduced this part of the Bill. Having a registered nurse on the board is so important. If we do nothing else in terms of the Francis report, the one thing that shines through is that you need somebody within the organisation who brings to the board those issues of quality care at every level. That is really quite exciting. I hope that my noble friend will listen to the wise words of the noble Lord, Lord Hunt, and others, and ensure that nursing is given a real place at the table, because quite frankly for generations it has not been. Nurses are no longer the handmaidens and “handmasters” of other professionals. They are in fact equals.

[Baroness Emerton]

My Lords, I support the noble Lords, Lord Hunt, Lord Turnberg and Lord Willis, in their recommendation that a registered nurse should be on the board.

An issue that Francis picked up after the report is that the nursing voices are not strong. He said he was disappointed in the response from the nurses. We now have to ensure that the nurses on the board are equipped with the knowledge and expertise to be able to speak out and hold their own. The training of senior nurses in standing at the board table and making their voices heard and understood on quality, safety and the patient experience is going to be very important. Therefore, it links very much with the leadership training, which we also need to address, in terms of their preparation. Perhaps the noble Earl will comment on that.

Care Bill [HL]

Debate between Lord Willis of Knaresborough and Baroness Emerton

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.

--- Later in debate ---

[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.