Oral Answers to Questions

Debate between Andrew George and Dan Poulter

Tuesday 24th February 2015 Commons Chamber

[Dr Poulter]

They are in the monthly staff statistics survey. As the hon. Gentleman would like some detailed information, I am sure he will be pleased to hear that in his constituency there are now 386 more nurses than there were in 2010 under the previous Government, and nationally there are 7,500 more nurses, midwives and health visitors working in the NHS.

[Andrew George (St Ives) (LD)]

Does my hon. Friend agree with me and with the nursing profession that if nurse staffing levels on acute hospital wards fall below one registered nurse to seven acutely ill patients, excluding the registered nurse in charge, it will significantly increase the risk to patient care and result in avoidable excess deaths?

[Dr Poulter]

My hon. Friend and I have discussed this many times and I do not agree with him, as he knows. What is important is that patients are assessed on their clinical needs. A rehabilitation ward will need a different number of nurses—indeed, it may need physiotherapists and occupational therapists—from intensive care nursing, which often requires one-to-one care, so setting arbitrary staffing ratios is not in the best interests of patients.

Oral Answers to Questions

Debate between Andrew George and Dan Poulter

Tuesday 21st October 2014 Commons Chamber

[Dr Poulter]

I hope that I can reassure the hon. Gentleman that there are now 1,000 more GPs in training and working in the NHS under this Government than when we came to power in 2010. We are committed to training even more GPs to ensure that we can widen access to general practice services.

[Andrew George (St Ives) (LD)]

In what circumstances can clinical commissioning groups treat the NHS as a preferred provider, and in what circumstances are they forced to contract out services?

[Dr Poulter]

As my hon. Friend will be aware, when commissioning services, it is important that regard is given not only to competition because, under the 2012 Act, we have ensured that there must be regard to delivering an integrated and joined-up approach for local services. That is an issue for local commissioners to decide in the best interests of the patients they look after.

Acute Hospital Wards (Staffing)

Debate between Andrew George and Dan Poulter

Wednesday 15th January 2014 Commons Chamber

[Dr Poulter]

As I will come on to say, if my hon. Friend will bear with me, it is now a matter for the CQC to inspect trusts on issues such as quality of patient care and safety. I will outline those measures later in response to my hon. Friend the Member for St Ives.

It is important that we support staff as much as possible when they raise concerns, whether about minimum staffing levels or other quality-of-care issues—this was the point just raised by my hon. Friend the Member for Stafford (Jeremy Lefroy)—and to do that we are facilitating and enhancing a duty of candour on trusts to ensure a more candid and open approach and to ensure that staff who have concerns are better supported and are better able to raise them.

Turning specifically to the matters at hand, superficially the principle of minimum staffing ratios sounds seductive, but when it comes down to it, we will see that they do not guarantee safe staffing or care. For those reasons, the Government do not support them. The principle of good care is about having the right staff in the right place at the right time. As we will all be aware, the needs of patients can change not just daily, but hourly—a patient can rapidly deteriorate—and just having ticked a minimum-staffing box does not mean that the right care is necessarily being applied. The lesson to learn from Mid Staffs is that we followed the bureaucratic tick-box approach and that led to failings in care, and that just ticking boxes saying we have done something, however seductive or good it might sound, does not necessarily mean that patients are being treated right. That is a matter of clinical circumstances and the clinical judgment of staff.

[Andrew George]

I am well aware of the Minister’s line, but if we followed its logic to its conclusion, we would withdraw minimum staffing levels from paediatric wards, intensive care and, in other sectors, child care, which is a topic that has been hotly debated politically as well.

[Dr Poulter]

As my hon. Friend will be aware, the CQC inspection regime inspects all parts of hospitals. Good care in a cardiac or intensive care unit is not necessarily about having one-on-one nursing; it is also about ensuring that all the other additional supports and other parts of the multidisciplinary team are in place to deliver high-quality care. That is at the heart of what the Government are trying to do. I believe that the CQC, looking not just at staffing levels but at wider determinants—for example, using the NHS safety thermometer, which looks at the issues my hon. Friend raised about bedsores—and putting together a whole picture of what the care at a trust is like, is well placed to make judgments. Part of the CQC’s inspection regime entails full clinical involvement, so it has become more of a peer-review process about what “good” looks like from one hospital to another—an important improvement in the quality of the inspection regime, which enables it to weigh up staffing issues.

My hon. Friend will be aware that we are going to support the CQC and provide greater transparency throughout the health system—in regard to staffing levels, by ensuring that they are published in future. Trust boards will have a requirement specifically to look at their staffing levels and to address problems. We shall not simply wait for the CQC to react to staffing issues as part of its wider inspection regime; there will be a requirement on trust boards to look at them. On Christmas day, I visited my local trust and found that staffing levels were discussed on a daily basis, in direct response to improvements following the Francis inquiry. I believe the same thing is taking place in a number of hospital trusts throughout the country.

Let me deal with my hon. Friend’s specific questions. He asked whether there were a significant number of hospital settings in which the number of registered nurses on duty was insufficient to ensure patient safety, professional standards and morale among many in the nursing profession. Our patients, their families and the public need to be assured that, wherever they are cared for and treated, there is a strong and positive patient safety culture, led from the top and embedded in every organisation.

There can be cases where hospitals are under-staffed and there is an impact on the quality of care provided, but these cases need to be addressed from a whole-care perspective, in which staffing numbers form just one element of a broader safety assessment. It is right that clinicians and trust boards have the freedom to agree their own staff profiles, which should not be dictated from Whitehall or by some blanket tick-box approach saying “You have met the minimum staffing number; you are therefore delivering good care”. We know from what happened at Mid Staffs that that is not the case. We must do everything we can to support good decisions made in the best interest of patients on the ground. This approach will give trusts the flexibility to respond swiftly to changes in patient demand or to meet the urgent needs of patients who have deteriorated, ensuring that safety and quality care is available.

We need to make sure that patient safety is a constant concern to each and every NHS trust and NHS employee, ensuring that risks to patient safety are always acted on as soon as they are identified, whether it relates to a “never event” or to the number of staff on a ward at any time of the day or night. We expect trust boards to sign off and publish information on staffing levels at least every six months to demonstrate that they are using evidence-based tools to calculate their staffing levels and provide assurance on the impact on quality of care and patient experience.

My hon. Friend asked whether the Safe Staffing Alliance proposal for a fundamental standard of no less than one registered nurse to eight patients would be a useful tool for inspection, surveillance and as a benchmark for management to use alongside other safe staffing tools. I hope he will understand that no single dimension and no single tool can ensure patient safety and that setting minimum staffing levels does not necessarily ensure that patients get the best possible care. Patient safety is not just about safe staffing; it is about listening to patients, assessing their needs and staff taking action where there are concerns. The number of staff—not just nurses, but doctors, physiotherapists, health care assistants and all other important members of a multidisciplinary team—needed to look after patients in a cardiac intensive care unit will differ from the numbers and skill mix required in a rehabilitation setting or another care setting—and it will differ from day to day, ward by ward and sometimes even from hour to hour, depending on the care needs of patients.

Ticking boxes on minimum staffing levels does not equate to good care. As the Berwick review made clear, ticking boxes in relation to minimum staffing levels does not equate to good care. Patients must be assessed individually, and the level of care required to ensure their safety must be determined by front-line staff locally, supported in their decision making by a range of factors that determine safe care. That should include staffing levels, but they are not the only issue: the Berwick review made that clear as well.

The Care Quality Commission also considers staffing levels in its inspections of registered providers, including acute hospitals. All providers registered with the CQC must ensure that at all times there are sufficient numbers of suitably qualified, skilled and experienced staff. In time, the guidance that we are developing on safe staffing will help providers to understand how to calculate reference staffing levels. It will also be used by the CQC when it assesses whether the right number of staff are employed to provide safe patient care.

My hon. Friend asked whether I agreed that in future the CQC should concentrate more on using safe staffing tools and clear measurements, and on how many registered nurses were on a ward. I do not want to dictate from Whitehall—indeed, I am sure that none of us do—the details of what the CQC will look for; it is important for the CQC to take a flexible approach to its inspections, and to be prepared to pursue different avenues depending on what it finds. What we can all agree on is that the provision of enough trained and skilled staff is vital to the delivery of acceptable care, and that CQC inspections should continue to consider staffing levels.

I must end my speech shortly, so I will write to my hon. Friend about the other points that he raised. I know that we are approaching this issue from the same position, and that all of us care about supporting staff and delivering high-quality care. However, I hope my hon. Friend will agree that safe staffing levels could have perverse consequences, that they are only a part of the picture when it comes to delivering good care, and that it is for the CQC to ensure that it takes an accurate and holistic view when carrying out its inspections to ensure that high-quality patient care is provided in the future.

Question put and agreed to.

Oral Answers to Questions

Debate between Andrew George and Dan Poulter

Tuesday 22nd October 2013 Commons Chamber

[Andrew George (St Ives) (LD)]

6. What the current (a) highest, (b) lowest and (c) mean average registered nurse-to-patient ratio is on acute hospital wards.

[The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter)]

As my hon. Friend is aware, we do not hold information on registered nurse-to-patient ratios on acute hospital wards. Local hospitals must have the freedom to decide the skill mix of their work force and the number of staff they employ to deliver high-quality, safe patient care.

[Andrew George]

I am grateful to my hon. Friend. The Government should be monitoring the situation, but he will be aware of the concern, which I have consistently highlighted, about inadequate registered nurse ratios in acute hospital wards, and of the Health Committee’s report into the Francis inquiry, which made recommendations in that regard. In inspecting hospitals, what objective measure should the Care Quality Commission use when looking at safe staffing levels on acute hospital wards?

[Dr Poulter]

The CQC is working with the National Institute for Health and Care Excellence and NHS England to devise tools to do exactly that. As my hon. Friend will be aware, the number of front-line staff required, whether nurses or doctors, to look after a patient who is in a cardiac intensive care unit will differ from the number required in a rehabilitation setting. The tools that the chief inspector of hospitals will be able to apply are being developed.

Oral Answers to Questions

Debate between Andrew George and Dan Poulter

Tuesday 16th April 2013 Commons Chamber

[Andrew George (St Ives) (LD)]

If there is a smidgeon of space in any of the Ministers’ diaries, is there a chance that they could meet me and representatives of the nursing profession to address not the issue that I think the Government are saying they are opposed to—mandatory nurse to patient ratios on wards—but that of adequate registered nurse levels on hospital wards?

[Dr Poulter]

Of course, I would be very happy to meet my hon. Friend to discuss this matter further. He can be reassured that I have regular discussions on these matters with representatives from the nursing profession, both in my clinical work and, more specifically, in my ministerial roles.

Oral Answers to Questions

Debate between Andrew George and Dan Poulter

Tuesday 27th November 2012 Commons Chamber

[Dr Poulter]

I fully agree with the hon. Lady and I take her concerns on board. However, because of the additional freedoms introduced by the previous Government, local employers in foundation trusts throughout the NHS have additional freedoms to set their own pay, terms and conditions. Under the rules introduced by the previous Government, it is impossible for us to intervene directly in the matter, except by continuing to encourage trade unions and NHS employers to meet the national agreements. If national terms and conditions are agreed to, I am sure that they will be endorsed at a regional level by the south-west consortium.

[Andrew George (St Ives) (LD)]

I am very pleased that the Minister will be meeting a cross-party delegation of MPs from the south-west next week to discuss this issue. In view of his answer to the hon. Member for Bristol East (Kerry McCarthy), is he confirming that Health Ministers have no powers at all to intervene in the negotiations between employers and their staff?

[Dr Poulter]

It is worth putting it on the record that it was the previous Labour Government who introduced foundation trusts in 2003 and set them free from direct accountability to Ministers. That includes the ability to set their own pay, terms and conditions. It was Labour that removed the power of the Secretary of State to direct foundation trusts, and it is Labour, not the Government, that needs to decide whether it supports the legislation that it put in place in government. We endorse national pay frameworks and will do all that we can to preserve them.

--- Later in debate ---

[Andrew George (St Ives) (LD)]

T6. There is mounting evidence that clinical care failure is as much to do with inadequate staff levels as anything else. In view of that, do Ministers agree that it is worth looking at the merits of establishing mandatory registered nurse to patient ratios across secondary and tertiary care wards?

[Dr Poulter]

I thank my hon. Friend for that question. This point has been raised before and although it sounds like a good idea in principle, the problem is that different aspects of care in different wards—for example, an older people’s ward compared with a ward that looks after younger people—will have differences in the intensity of nursing. Therefore, a mandated ratio would be difficult to implement. A ratio may be counter-productive to making sure that we can give more intensive nursing cover where it is needed, and could even encourage a race to the bottom.

Health and Social Care Bill

Debate between Andrew George and Dan Poulter

Tuesday 20th March 2012 Commons Chamber

[Dr Poulter]

I rise to speak in support of the Government, and of what the previous Government did for the NHS. When the shadow Secretary of State was Secretary of State for Health—the same was the case with many of his predecessors—there was a consistent policy whereby the private sector should be used where it could add value to patient care in the NHS. That was done very effectively by the previous Government to bring down waiting times for operations, but it was not effective when it was not done in an integrated way. Very often, it was done without regard to post-discharge planning for patients but, as we heard earlier, the renewed focus on integration should help to deal with those problems.

We have some of the very best hospitals not only in this country but in the world, including the Royal Marsden and Moorfields eye hospital, where a relatively high proportion of activity is carried out by the private sector. No one doubts those hospitals’ commitment to their NHS patients or that they still provide those patients with the very high standards of care of which health care systems in other countries are very envious. We are very proud of what those hospitals do, and the Government would like to give other hospitals the same opportunity and freedom to follow their example. The Government believe that it is absolutely appropriate that we should use the private sector where it can enhance value to NHS patients. That is absolutely consistent with the previous Government’s policies, for which many Labour Members campaigned at the last general election. This Government are also committed to those policies.

[Andrew George]

I understand and respect the sincerity of the principle that my hon. Friend is describing, but can he reassure me, particularly given his understanding of the NHS and health systems, that under these proposals it would not be possible for a foundation trust to drive some NHS patients towards the private arm of the activities that they undertake, particularly in the case of procedures that are exactly the same in the private and the public sector?

[Dr Poulter]

My hon. Friend makes a valid point, and he is right to raise it. That happened in the past when, under the previous Government, private sector providers were paid 11% more for the provision of services than NHS providers, which created an incentive for the private sector to be used ahead of NHS services. This Government are committed to ensuring that that does not happen. My hon. Friend the Minister and my right hon. Friend the Minister and Member for Cheltenham—[Interruption.] I mean Chelmsford; I apologise, particularly as I get the train through his constituency on the way home every Thursday night. They have clearly stated that the Bill is about making sure that we use the private sector when it adds value for money. The hospital that uses the private sector the most—the Royal Marsden—does not have a two-tier service for NHS patients and private patients. The involvement of the private sector at that hospital greatly enhances the work of the NHS and the quality of service and care available to its NHS patients because of the increased research that is performed, the high quality of care, and the high standard of clinicians who are attracted to work there. That works well for the private sector and for the NHS.

I agree with the right hon. Member for Bermondsey and Old Southwark (Simon Hughes) that, where possible, we should be using NHS providers. The Royal Marsden, where there is a high potential cap on private sector involvement, does not use the full capacity of that cap, and there is less private sector activity than it could undertake. That is because the Royal Marsden says, in effect, “Yes, the private sector is good, but it is not only about maximising our cap and maximising our profits but taking into account the best interests of our local patients and striking a balance.” That works very well.

[Andrew George]

As I understand it, the majority of the private work at the Royal Marsden is in areas such as research and development that are not in any way similar to the services it provides to NHS patients. I asked my hon. Friend whether he agreed that where the private sector and public sector were providing the self-same services for NHS patients, there was a risk that patients might be driven from the NHS towards the private sector.

[Dr Poulter]

I hope I reassured my hon. Friend with my earlier answer. Yes, he is right that that has happened in the past. However, there is a presumption in the Bill—particularly for rural areas such as Cornwall and in Suffolk, which I represent—that the renewed focus on integrated care that we heard about earlier is the primary focus and purpose of commissioning, over and above the use of any willing provider or private sector providers. That has given me great reassurance regarding our ability to take on and deal with the big demographic challenges of looking after older people better.

I am reassured by what the Minister has said, and I urge Government Members to support the Government.