Nursing

Lord Young of Norwood Green Excerpts

Thursday 1st December 2011 Lords Chamber

[Lord Young of Norwood Green]

My Lords, I, too, thank the noble Baroness, Lady Emerton, for initiating this debate and congratulate her on a superb contribution. I enjoyed the history of nursing but must admit that I felt that one name was absent—especially as we are talking about front-line nurses—and that was Mary Seacole, who brought a different approach, though a very interesting one, about the same time as Florence Nightingale. I see that I have not transgressed because the noble Baroness is nodding. I am relieved that I have got my history right.

I enter this debate as a lay person, but I cannot help thinking that if Benjamin Franklin were alive today and living in the UK, he might be saying that there are three things that are certain: death, taxes and—whoever we are, at some point in our life—being impacted on by the National Health Service. Of course, the unfortunate fact is that as we gradually mature—I do not say get older; in the House of Lords we mature—we experience that impact. Last year I spent a week in an NHS hospital having a large lump of titanium inserted in to my hip. It was largely a very good experience. It was fascinating being in the ward, looking at the atmosphere there and the nature of the people who treated me. As has been said, some were absolutely superb: they had empathy, compassion and all the things that you want. Others, I could not help feeling, needed to be taken to one side and told, “Look, part of working on a ward is to show care, empathy and compassion. If you’re not doing that—it doesn’t matter who you are, whether you are a doctor, nurse or care assistant—you are actually undermining the quality of care for people who are really at your mercy as patients”.

When it is good, it is really good. I noticed this during that week. There were some ward sisters who came on and would do anything; never mind “too posh to work”, they would do any job whatever. They were a brilliant example of leadership at its very best. There were others with whom I felt that it was not quite right. The worst example that I saw was when the elderly woman with suspected pneumonia in the bed next to me was getting in to that panicked breathing mode. In a plaintive voice, she said, “Help, nurse. Help”, and a young nurse who was sitting at a computer turned round and said, “Someone will be along in a minute”. I had difficulty in restraining myself at that point and fortunately someone did come along, but why did that nurse not get off her backside and do what she should have done, which was to respond to the woman while holding her hand? It is a matter of changing the culture—something that has already been referred to. I hesitate to bring up the worst examples but, if we do not have an honest and frank debate, we will not really address the issue.

However, as I said, I have seen some wonderful examples. My wife is currently being treated for a serious kidney condition and the renal ward at Hammersmith Hospital is absolutely brilliant. I reckon that the senior ward sister there—Sister Nicola—would be able to solve most of the problems in the National Health Service if only we could clone her. She is marvellous and empathetic, and the ward runs like clockwork, and so there are some absolutely brilliant examples.

My noble friend Lady Warwick rightly condemned the generalisation that takes place in the media by implying that, if you have a degree as a nurse, somehow you cannot undertake basic nursing tasks. I, too, reject that—it is clearly wrong. However, we have to make sure that the training for people who study for a nursing degree is right. As I understand it, they should spend 50 per cent of their time on the wards. I should be grateful if the noble Earl, Lord Howe, could confirm whether that is the case when he responds. Ward experience under the watchful eye of trained sisters is vital.

My noble friend Lord Hunt, who seems to have captured the ground in progressive approaches to the development of nursing, gave us some very useful pointers. Why do nurses not have something equivalent to the doctors’ Hippocratic oath? My noble friend was absolutely right to talk about a code of values. That ought to be taken on board and be a part of the national scheme. Knowing who is in charge and has authority is important. Going back to one of the best examples that I had experienced, when I asked Sister Nicola what her qualifications were and whether she had been in the nursing profession for a long time, I discovered that she actually had only a diploma. I am not arguing against degrees but, with my passion and enthusiasm for apprenticeships, I argue that there should be a vocational route into nursing. Interestingly, when I asked the consultant for her views on this, she said, “It’s funny you should say that. We have a healthcare assistant who is a mother. She has returned to work recently and wants to go into nursing”. There ought to be that vocational route for healthcare assistants. I am reminded of the old sandwich courses that you did if you wanted to get a degree in engineering. Again, when the noble Earl replies, I should be grateful if he could take up that point.

The noble Baroness, Lady Browning, said that there are a number of practical things that can be done—my noble friend Lord Hunt told us about some of them—and that we do not need another five years of research to encounter what we know to be proven good practice. I hope that the noble Earl, Lord Howe, will be able to assure us that spreading best practice will be one of the Secretary of State’s key roles. It is not just about money; there is a real debate about staffing, although I do not want to go into that. Obviously if people feel under real pressure, that is going to create problems. I do not particularly want to explore that side of the issue but spreading best practice, as a key part of developing the health service, seems to be fundamental. Surely it would be a cost-effective, value-added method of improving the health service.

I have one or two points to make in conclusion. The noble Baroness, Lady Browning, touched many buttons when she talked about the confusion over uniforms. I absolutely echo that. You think, “That one’s in blue, that one’s got blue with spots on and that one’s in pale blue”. Sometimes it is also really difficult to distinguish healthcare assistants.

There is a question over whether healthcare assistants should be regulated. I tend to feel that, because they have become so important to hospitals and community care, the one thing that we should insist on is a requirement for basic training. That should not be an option. Perhaps a code of values, which my noble friend Lord Hunt suggested in relation to nurses, should also be adopted for care assistants.

A number of contributors said that it was important to make sure that those in charge of wards have authority. I have recently been in hospitals where the wards have been spotlessly clean. That is one part of the problem in wards but it is not the only one—noble Lords have also referred to the feeding of patients and so on.

I am conscious of the time but I should like to make a final point. I think that it was on the “Today” programme on Radio 4 this morning that I heard a former nurse speaking about whistleblowing. I do not like that phrase either, because it should not have to happen. The right management environment should encourage people, as part of working in a team, to explore the strengths and weaknesses of their work on a ward. They should be able to say, “How can we work together? If there are problems, I should be able to feel that I can go to my immediate manager and have a frank discussion”. It is important to ensure that the right processes are in place to enable nurses to feel confident enough to do that.

In conclusion, I feel privileged to have had the opportunity to take part in this debate and I look forward to hearing the noble Earl’s response.

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

My Lords, on occasions like this, I reflect on how lucky we are in this House to have the noble Baroness, Lady Emerton, in our midst. She has allowed us to appreciate once again why she is such an unquestioned authority on this crucial subject of nursing care. I, for one, am very grateful to her.

The wording of her Motion is of course carefully chosen. Front-line nursing—in acute settings, in the community, in schools and in people’s homes—is a part of all our lives and has always been an essential element of patient care in the National Health Service. Patients are clear about what good nursing care should look like. They want to be confident that their nurses are knowledgeable, safe and competent. They expect their nurses to be caring and compassionate. They want to be treated with respect by nurses who genuinely care for them and about them.

We in Government are also clear about what we expect from a front-line nursing workforce. I cannot better the description offered by the noble Baroness, Lady Warwick. We expect high-quality, safe and knowledgeable care for all; we expect dignity and compassion for all; and we expect nurses to make the most of each and every interaction they have with patients to improve their health and well-being, and their experiences of care.

What makes a good nurse? The first requirement is a point raised by my noble friend Lord Bridgeman. We should attract people into the profession who not only have academic ability, but also have the right values, attitudes and behaviours. Education commissioners expect universities to demonstrate that their recruitment processes embrace this approach. Employers will also look for this as part of their selection and recruitment processes when they are helping to interview potential students and are appointing registered nurses. Getting this right at the start will help to reduce attrition and maximise the resources that we put into nurses.

The second requirement, as our debates on the Health and Social Care Bill have amply demonstrated, is that we educate and train our nurses well. The Nursing and Midwifery Council undertook a comprehensive review of pre-registration education and published new standards for pre-registration education in 2010, following extensive and wide public consultation. Importantly, fundamental care is specifically reflected in these new standards. I would say to my noble friend Lord Bridgeman that student nurses spend as much time gaining practical, hands-on experience with patients as they spend in the classroom. In fact, I believe that that ratio has not changed over the past 30 years. I completely agree with the excellent points made by the noble Baroness, Lady Warwick, about degree-level nursing. The first of the new educational programmes began only this year and it will be about three years before the first students emerge from these new programmes. The NMC will evaluate these changes and I look forward to seeing this work.

The next requirement is to enable nurses to nurse. That means doing what the noble Baroness, Lady Masham, talked about so compellingly: finding ways to make sure that we keep senior, experienced nurses beside patients delivering hands-on care and not filling in endless piles of paperwork, which are sometimes of marginal usefulness. That is why we are committed to reducing bureaucracy and empowering our nurses as clinical leaders. The NHS institute’s productive series is helping nurses to reduce unnecessary and wasteful practice at the point of care, which is freeing up nursing time to be spent on essential tasks, such as providing assistance with mealtimes and carrying out interventions to prevent pressure ulcers and falls. Any good nurse will tell you that spending more time with the patient facilitates a better and more timely patient assessment, thus enabling the nurse to spot signs of deterioration or to pick up on small but significant things that a patient often will not think to mention. That is why my officials are working with the NHS institute to explore ways in which areas that are not yet embracing the productive series can be identified and supported with implementation, thus allowing the spread of best practice, about which the noble Lord, Lord Young of Norwood Green, spoke.

A phrase that I have learned recently is “essential rounding”, a system that sees nurses doing planned rounds every one to two hours to check on patients and to deal with any concerns. We are pleased to see nurses embracing that concept. Feedback about it from patients and nurses is very positive, with some studies seeing a reduction in falls and improvement in patient experience since implementation. In fact, a plethora of best-practice guidance is available. But central initiatives can take us only so far, which is why effective nursing leadership at the front line is so important. Matrons and senior nurses are role models and they are pivotal in developing the culture of care in their clinical areas. Through the standards they set for others to follow, to monitoring the performance of individual nurses, they ultimately make the difference between good and bad care.

I welcome the work of the NHS institute in developing a clinical leadership competency framework which will help develop patient-centred nursing leadership. The noble Lord, Lord MacKenzie, whom I welcome to the Front Bench, was right that the vast majority of nurses are extremely professional, care deeply about their patients and do a tremendous job, often under very difficult circumstances. But, at the same time, the noble Lords, Lord Young and Lord Hunt, were right to be honest that this is not always the case. The CQC’s report on its 100 unannounced nurse-led inspections showed how the quality of care—in this case, for older people—can fall far short of what we would want. That problem is far more widespread than we would expect. About half of hospitals visited gave cause for concern. Twenty hospitals were not delivering care that met the essential standards that the law says people should expect. I was alarmed to see that in 14 hospital trusts fewer than half the staff said that they would be happy to see a friend or relative treated in their own hospital.

However, I would say to the noble Lord, Lord MacKenzie, that I do not think that it is right simply to say that this is because of poor staffing. The CQC dignity and nutrition inspections found many examples of excellent practice where staffing was not ideal and cases of poor nursing care where there was a full staffing complement. We are hearing more and more concern from patients and nurses themselves about inadequate staffing levels and inappropriate use of support workers. As I said in our debate yesterday, setting safe staffing levels is not an exact science. These decisions are complex and they are best made by local clinicians and managers on the ground, who understand the needs of their patients. As noble Lords are aware, there is guidance available from the RCN and others to assist clinicians and managers in setting safe staffing establishments.

This same guidance is used by the CQC when determining whether providers have enough suitably qualified, skilled and experienced staff. The CQC can take tough and independent action when an organisation is not taking appropriate steps to ensure that there are sufficient numbers of suitable staff at all times. The noble Baroness, Lady Emerton, mentioned Anne Marie Rafferty’s research. I would be pleased to look at that research in detail and I will ask the Nursing and Midwifery Professional Advisory Board to consider it and report back to me early in the new year.

Much of the concern around nursing in acute settings has been related to inappropriate delegation by nurses to healthcare support workers. Wherever there is a multidisciplinary team of regulated professionals and unregulated healthcare workers, appropriate delegation and supervision is vitally important. This is an area ripe for formal review. We very much welcome the NMC’s plans to update its guidance on delegation so that nursing staff know how to do this safely and are clear that they retain responsibility for their actions. We have also asked Skills for Health and Skills for Care to accelerate production of a code of conduct and recommended core training for healthcare support workers and adult social care workers in England. We expect work to begin by April 2012, with the aim of delivering outputs ahead of the establishment of an assured voluntary register, which could be operational from 2013 onwards.

Nurse leaders, managers and trust boards must take staffing concerns seriously and, where staffing is found to be an issue, they must take immediate action. In the new world of the NHS, there will be two watch words for commissioners: outcomes and quality. This carries the basic point that clinical commissioning groups will want to satisfy themselves that the services they commission have safe and effective staffing profiles. Nurses will have an increasing role in commissioning and in developing the shape of local services—that is exciting.

Safe and effective care has several strands to it, all in the direct gift of nurses. Noble Lords may be aware of the QIPP safe care work stream quality improvement programme—the safety thermometer—which aims to focus nursing attention on four areas of harm: falls, blood clots, pressure ulcers and catheter-related urinary tract infections. We have published the 2012-13 operating framework with strong messages about reducing harm in these areas, making sure that these are firmly on trusts and commissioners’ agendas.

My noble friend Lady Browning spoke of the need for government leadership and she is right. We are making sure that the nursing contribution to quality is being championed at the very centre of government. The SHA chief nurses are leading the nursing contribution to quality improvement at the front line through the energising for excellence quality framework. Much of the success of the quality framework will depend on transparency and, as part of our transparency agenda, NHS North is working towards local publication of nurse-sensitive metrics in areas such as falls and pressure ulcers and is also exploring how best to include patient and staff experience data. The patient experience is absolutely centre stage as we set about measuring the quality of nursing care. Ensuring that patients have a positive experience of care is reflected in the NHS outcomes framework that the new NHS Commissioning Board will use to hold the NHS to account for what it delivers. Everyone who works in the NHS has a role to play in ensuring that patients have a good experience. It is not optional, and it is not “someone else’s job”. The task is to make listening, understanding and responding to patients’ views as commonplace as acting upon clinical audit data, patient safety data or financial data.

Nurse training has, unsurprisingly, featured prominently in this debate. The noble Baroness, Lady Warwick, raised the issue of continuous professional development. Later this month, the Government are publishing our detailed proposals on education and training that will describe the arrangements for continuing professional development, which we recognise is of great importance. My noble friend Lady Jolly spoke about the role of specialist nurses and her concern about downgrading roles without due regard to patients’ needs. I agree that service planning has to put patients firmly at the centre. The Government acknowledges the important role of specialist nurses in improving health outcomes and patient experience. In the end, local organisations must have the freedom to determine the skill mix of their clinical teams. Commissioners, clinicians and trust boards have to work together to ensure that the workforce is capable of meeting the needs of patients and that they have access to continuing professional development.

My noble friend also spoke about the introduction of end-of-life care standards, and I am happy to assure her that we will continue to work towards implementing the end-of-life care strategy.

The noble Baroness, Lady Masham, spoke with her customary force about bringing back old-style matron. That resonated throughout your Lordships’ Chamber, and there is no doubt that strong nursing leadership is essential at all levels for high-quality care. The noble Lord, Lord Hunt, was quite right about that. Directors of nursing and trust boards must set the culture for a hospital, and that includes a leadership style that challenges poor standards and creates an environment for high standards.

My noble friend Lady Browning raised the subject of whistle-blowing. It is very important that the culture of a hospital is right to enable whistle-blowing to happen. Leadership from boards has to set the tone for that. To whistle-blow does require great confidence and support. I believe that more of this will come because of the increase in graduate nurses.

All this has a direct bearing on the point made by my noble friends Lord Bridgeman, Lady Browning and Lord Ribeiro about cleaning. Nurses have a key role to play in ensuring that hospitals are kept clean. The infection control nurse, the ward sister and matron who set and enforce local standards are particularly important. The code of practice for the prevention and control of infections ensures that nurses are involved in all aspects of cleaning standards. The code provides that directors of nursing are involved in all cleaning contract negotiations, which is very important. Matrons have personal responsibility and accountability for delivering a clean safe environment for care.

The noble Lord, Lord Hunt, mentioned supernumerary sisters. The RCN has just published guidance on developing business cases to fund the supervisory status of the sister so she can exercise her leadership role effectively. The guidance is helpful, timely and above all very practical.

The noble Baroness, Lady Masham, spoke of the importance of district nurses—again, absolutely to the point. We acknowledge the enormous contribution of district nurses in helping people manage long-term conditions, keeping people out of hospital and ensuring people are able to access the resources they need, when they need them. We want to make sure that people go to hospital only when they need what a hospital can do. We see a much greater role for district nurses in the future, not a diminishing one.

The noble Baroness, Lady Warwick, and others mentioned the RCN Frontline First report. I do not want to dwell too long on this, but I have to voice some serious criticism about that report. The RCN’s numbers are mainly based on an analysis of just 41 trusts. The trusts identified in the report have disputed the RCN’s figures. The RCN has not offered commentary on the fact that some of these plans are about moving services out into the community to provide better care for people when and where they need it. We are not disputing that some trusts have reduced the number of staff—some have—although many of these are support staff and often it is being done through natural turnover. We do emphatically reject the conflated numbers that the RCN is claiming. I have got some chapter and verse in my brief, but all I would say is that it is up to local trusts to determine their workforce needs. We have made it clear that any reduction in clinical posts must not have an adverse impact on the quality and safety of patient care. We have introduced a quality assurance process for SHAs to complete with trusts.

The noble Lord, Lord Patel, spoke about midwifery. The Government are not reducing the number of midwifery trainees. In 2010-11, 2,488 midwives training places were planned. A further 2,507 training places are available this year—that is a record high. The Government are committed to ensuring that we have the right number of trained midwives, especially given the increased number and complexity of births in recent years. This includes ways of supporting midwifery recruitment and retention to help local organisations which are able to commission the number of training places that they need. We have asked the Centre for Workforce Intelligence to undertake an in-depth study of the maternity workforce starting this year. This will inform the future commissioning of training places, including for midwives.

On specialist neonatal nurses, I took the points that the noble Lord made. The National Institute for Health and Clinical Excellence quality standard and the toolkit for high-quality neonatal services are valuable tools to assist NHS commissioners and providers in the provision of high-quality care for babies and their families. However, I shall take away the points that the noble Lord raised.

We have heard today from my noble friend Lady Jolly, among many others, about the opportunities for front-line nursing. Technology moves on, medical knowledge is constantly advancing and the members of our nursing workforce will need to keep abreast of these changes. But one thing that we know will not change is the importance of the care that nurses deliver; and the key role that nurses can and do play in improving quality of care, patient outcomes and their experiences of care.

[Lord Young of Norwood Green]

Will the noble Earl comment on my point about a vocational route into nursing?

[Earl Howe]

In the time available, I shall do so very briefly. Access to nursing is, as the noble Lord will know, already through quite a wide entry gate—through progression from apprenticeships, NVQs and access courses. Universities set the entry standards and do not always rely on A-level qualifications. However, it is important that students must be able to cope with degree-level study—it would be wrong to set them up to fail. However, we are aware that the entry gate about which the noble Lord, Lord MacKenzie, spoke needs to be as wide as reasonably possible.

It is patients who matter most. As a Government, we are committed to bringing about the improvements in front-line nursing care that patients want.