Health and Social Care Bill

Baroness Emerton Excerpts

Wednesday 30th November 2011 Lords Chamber

Moved by

[Baroness Emerton]

138: Clause 20, page 20, line 2, at end insert—
“13O1 Duty as to staffing ratios of registered and non-registered staff
(1) The Board must, in the exercise of its functions, establish for health services, and may subject to regulations establish for other services, the ratio of registered to non-registered workers required at any given time by reference to any appropriate register established for workers in those areas.
(2) In the discharge of this duty the Board must publish a list of appropriate registers for the purpose of subsection (1).
(3) The Board must produce guidance to health services to assist in the maintenance of ratios for the purpose of subsection (1).
(4) The Board must also issue guidance on the maximum and minimum numbers of patients per registered nurse.”

[Baroness Emerton]

My Lords, while workforce planning is to be a devolved activity at local commissioning level, this Bill states that the overall duty of the national Commissioning Board is to arrange the provision of services for the purposes of the health service in England. Therefore, it would seem appropriate that the national board undertakes to give guidance on a range of issues, as some have already stated, and I would like to see this amendment added. I declare an interest as recorded in the register, speaking as a retired nurse, not named, on the NMC effective register.

The commissioning of the nurses, midwives and health visitors workforce is complex. It covers the community and hospitals; projecting numbers to meet the training requirements; commissioning university places with the right numbers for the services to be provided; and establishing the right number in the right place at the right time. In practice, this requires skilled planners who understand 24-hour service and the different levels of dependency in each speciality, to effect holistic care in hospitals and the community. The economic situation we find ourselves in is already having an effect on workforce numbers. Only a week ago the Royal College of Nursing reported on the effects that the Nicholson £20 billion cut is currently having on services. The detailed analysis by the RCN of 41 trusts revealed that clinical posts were affected, or were planned to be affected. An analysis of the trusts in England showed that the reductions are not only contained within administration, management and other back-room offices, but also affect nursing. Registered nurses are being affected by the freezing of their posts, leading to lower staffing levels, the down-banding of high-grade nursing posts, the loss of specialist skills and those working in preventive services, and cuts in the mental health field, where demand for nursing is rising.

This spells disaster for patients and their families. We know that in Mid-Staffordshire the nurse staffing ratios were changed from 60 per cent registered and 40 per cent support workers, to 40 per cent registered and 60 per cent support workers, in order to make financial cuts, but at what expense? It does not need much intelligence to see that nursing care suffered and the effect was dire.

International research evidence clearly demonstrates that low nurse staffing levels correlate with higher patient mortality and morbidity. We know from evidence in the UK, the United States and Australia that the quality of patient care is affected by the ratios of registered nurses to support workers. The higher the ratio of registered nurses to support workers, the higher the quality of clinical outcome, providing faster throughput and reduced infection rates that in turn reduce readmissions. In addition, the patients receive safe care, and they favour it by way of experience.

To give an example, in a US study, every one patient added to the average hospital-wide nurse workload increased the risk of death following common surgical procedures by 7 per cent. There was a 31 per cent difference in mortality between hospitals in which registered nurses cared for eight patients each and those in which nurses cared for four patients each, taking into account the severity of the patients’ illness, comorbidity conditions and the level of technology and teaching status in the teaching hospitals.

A study in the UK in 2007 found that patients in NHS hospitals in the upper quartile, where nurses had the heaviest patient workload, were 26 per cent more likely to die overall and 29 per cent more likely to die following a complicated stay in hospital. The nurses in the hospitals with the heaviest workload were between 71 per cent and 92 per cent more likely to show negative job outcomes, burnout and job dissatisfaction, and to rate the quality of care on their wards as low and the quality of care in their hospitals as deteriorating. Similar evidence was produced in Australia.

The Bill works towards high-quality, integrated holistic care. Equally important as plans for the hospital workforce in nursing and midwifery are those for the community workforce: community nurses, midwives and health visitors. Last week, the Queen’s Nursing Institute published a report entitled Nursing People at Home, which demonstrated worrying trends in community nursing that could be remedied if more nurses were specifically trained, year on year, to work in the community. It recommended that there should be support for the newly qualified through preceptorship; that healthcare assistants should be regulated; and that commissioners of services should set standards for the qualifications of community team leaders. Likewise, the Royal College of Midwives launched a report last week into the state of maternity services in 2011, recommending that more births take place in midwife-led units and at home, that properly trained and supervised midwife support workers should be appropriately deployed and calling for a guarantee not to cut midwife training places.

There is a common thread running through the recommendations of all three professional bodies that, in essence, supports the amendment. There is widespread concern across the professions that, unless the national Commissioning Board issues guidance on staffing ratios, local commissioning of the workforce could lead to unsafe ratios of trained to untrained staff, resulting in unsafe care and increased cost to the NHS. It is a false economy to meddle with safe ratios. It would be more effective to move quickly towards a totally registered nursing workforce in hospitals, knowing that patients were receiving holistic, high-quality care, leading to shorter stays and reduced readmissions to hospital, resulting in bed closures and real savings.

There is no need for me to go in to more detail. The current situation is very bleak and we are in the midst of amending a Bill that aims to improve the health of the nation and provide high-quality care in hospitals and the community. The latest report and front-line survey by the Royal College of Nursing expresses concern, especially on the urgent issues that face the nursing profession if growing demand is to be met, with the demographic figures showing an urgent need for care of the elderly, the vulnerable, those suffering from long-term conditions and those requiring end-of-life care. We continue to trot out, at every opportunity, that evidence-based clinical care is essential. Will the Minister consider the inclusion of guidance concerning the issues raised by this amendment as a duty of the national Commissioning Board? I beg to move.

[Lord Alderdice]

My Lords, I have a good deal of sympathy with the thoughts behind the amendment in the name of the noble Baroness, which she has put forward in her usual forceful but thoughtful way. However, there is difficulty in some areas.

The amendment does not state so clearly but it appears to assume that registered and non-registered are the same as trained and untrained. I also draw your Lordships’ attention to something to which I have returned fairly regularly for more than 10 years, the fact that psychotherapists and counsellors are not registered. There is no statutory registration, and yet there are areas of care—for example, in alcoholism and drug addiction, child and adolescent psychiatry and psychotherapy, the care of some very disturbed patients—where psychotherapists, particularly trained ones, and counsellors are extremely important.

Many of these are people with very long trainings, much longer than would be the case, for example, for a nurse. They are well trained people and they are well supervised but there is no register and therefore they would fall foul of a proposal like this. Were it the case that all the appropriate people were not only trained but registered and that therefore one knew that those who were not registered were not fully trained and supervised, I would have a great deal more sympathy with the detail of it.

I have difficulty not with the thought behind this amendment but with the fact that it seems to some extent to ignore some quite important groups. My fear is that if we move down this road, in the new world the pressure will be further against the employment of people who have had substantial psychological training. It has been made clear to me—this is one of the reasons why I use this opportunity—that some of those with a high level of training and a substantial length of experience are already feeling themselves marginalised because the larger professional groups that have registers are using that to strengthen up the stance of their members, which is entirely justifiable and entirely reasonable.

I would be much more reassured and much more able to support the amendment if either it was very clearly and simply referring to trained and registered nurses or unregistered people who are working in nursing, rather than the more general statement which is in the amendment, or—perhaps even better—if my noble friend the Minister was able to indicate that the Government were going to make progress on the registration on those other groups that need to be registered; that involves in particular, from my point of view, psychotherapists and counsellors. However, I do have a good deal of sympathy with what the noble Baroness says.

--- Later in debate ---

[Earl Howe]

My Lords, these amendments from the noble Baroness, Lady Emerton, clearly reflect an important issue: that there should always be appropriately skilled staff available to meet a patient's healthcare needs. I appreciate the concern behind the amendments and recognise the central point of principle; nor am I in a position to contest the evidence that has been cited by various noble Lords. I do not wish to do that. Where I am afraid I part company with the noble Baroness is in her argument that it would be appropriate for the board to mandate staffing levels or skills mix within local services. Although she would probably expect me to say this, these decisions really are best made by local clinicians and managers on the ground.

As the noble Baroness will know, determining staff requirements is not an exact science. The number of staff on wards and ratios between nurses and patients, and between nurses and healthcare assistants, will vary according to such things as the individual needs of patients, their levels of acuity and dependency, the nature of the clinical care they require and the layout of the clinical area. It is right that nurse leaders, doctors and managers have the freedom to agree their own staff profiles. This gives them the flexibility to respond swiftly to changes in patient demand to ensure safety and quality. Rigid ratios really are not the way to do this.

In being responsive to different situations, providers of NHS services are expected to meet their obligations under the NHS constitution—which, incidentally, they do not have in California. This states that patients have the right to be treated with a professional standard of care by appropriately qualified and experienced staff. Suggested nursing staff ratios and the proportions of registered to unregistered staff are, of course, available from, for example, the Royal College of Nursing. But it would itself say that these should be used only as a guide and as the basis from which to ask questions about staffing if there are wide variations from the suggested norms. The amendments say the board’s duty is to establish or mandate “the ratio” as a legal requirement. That is simply not appropriate.

The other reason why I resist these amendments is that there is already a regulator overseeing these kinds of safety issues. All providers of regulated activities, including NHS providers, must be registered with the Care Quality Commission and meet the essential requirements around safety and quality. These include a requirement to take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purpose of carrying on the regulated activity. That is an essential standard. Compliance with it is assessed as part of the registration process as well as ongoing monitoring. So it is not, as my noble friend Lord Newton suggested, just a question of a snapshot.

What follows from this is that it is unacceptable for organisations to persistently fail to ensure that there are enough skilled and competent staff to deliver the care required; and the Care Quality Commission can take independent action where an organisation is not taking appropriate steps to ensure that there are sufficient numbers of suitable staff at all times. If the CQC judges that an organisation has failed to comply with any of the requirements for registration, then that organisation has committed an offence. That is a very powerful sanction. So while I completely agree that it is important to monitor these issues carefully, I do not agree that it is necessary to create a role for the board in this regard. A role for the board would prevent the necessary flexibility in local decision-making, and interfere with the role of the Care Quality Commission, and indeed the future role of Health Education England. That would not be desirable.

Various questions were asked of me about other professional groups besides nurses. I happen to know that, in answer to the noble Lord, Lord Walton, clinical psychologists are already subject to mandatory registration with the Health Professions Council under the title of practitioner psychologists. As regards other groups, a number of points were raised about non-registered workers, including their education and training, and the Government’s position with regard to those matters. I suggest that we will come to those matters when we reach Part 7, and it is perhaps more appropriate that we tackle them at that point.

The noble Baroness, Lady Thornton, asked me whether the Department of Health was aware of the problem of down-banding. We are aware of concerns in this area from the Royal College of Nursing and others. We are of course committed to ensuring that safety is a priority across the NHS, and we are looking at the concerns within that context.

That is essentially the Government’s position. It is not that we are unsympathetic to the point of principle to which the noble Baroness has drawn attention, but we think that there are mechanisms already in place to address those issues, and that it is essentially a matter of local and clinical and managerial judgment.

[Baroness Emerton]

My Lords, I thank the noble Lords who have taken part in this debate, which has opened up many questions. I thank the Minister for his answer. There is one point that I would take issue with, which is the Care Quality Commission, because it is almost too late if the Care Quality Commission comes in when there is a failing. We are trying to prevent failings, and move forward. There is an issue there, in determining the ratios.

I agree that it is for the local commissioners to be involved in the planning, but it is such a complex issue that, as we move into the care quality groups, there is an issue in terms of their expertise in being able to do this. This is why I raise the issue, supported by the Royal College of Nursing, which is very close to the scene. I appreciate that that is where it should be, and perhaps the way forward is to make sure that there is training in the workforce planning issues. It is complex. As has already been said, it concerns not just nursing but also the other disciplines. The evidence that has been shown ought to be followed up, and I ask that the Minister take that away, so that we can look at the evidence. There is an article today in the nursing press demonstrating quite clearly that morbidity and mortality is reduced by a higher level of trained staff. On that basis, I beg leave to withdraw the amendment.

Amendment 138 withdrawn.