Care Quality Commission (Fees) (Reviews and Performance Assessments) Regulations 2016
Baroness Walmsley Excerpts(8 years, 7 months ago)
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Baroness Walmsley (LD)
My Lords, it strikes me that this situation is rather like sending out the lifeboat to a swimmer in trouble in the sea and, instead of pulling him on board, pushing him further under the waves.
The issue raises a number of questions in my mind. First, is it right that providers should be expected to pay fully for the regulator, resulting in a dramatic increase of 75% in a single year and, I have been told, of 176% over the very short period of two years? If the Government believe that the CQC inspection is the “single definition of success”, they should be expected to pay for some of that quality assurance on behalf of the taxpayer, at least in the short term, in order to achieve the sustainability that we need not just for the CQC but for individual providers.
Over what time period should this new demand on the finances of providers be implemented? How much notice is being given? There were two days for implementation. That does not strike me as sensible, because it allows absolutely no time for proper budget planning.
The other question is whether providers can afford it. In particular, small GP practices in rural areas, I have been told, will be paying 1.75% of their turnover for the CQC. No wonder GPs are charging care homes for attending their residents, even though they already receive a per capita payment for them. What about the care homes, many of which are unprofitable even now? Let us face it: they are businesses—60% of patients are in private care—and we are heading for mass closure, which will be a disaster for all the old and vulnerable who need care.
As the noble Lord, Lord Hunt, said, what else will have to be cut from the front line in order for providers to pay for this at a time of unprecedented financial pressure? It will cost £28.7 million over four years, which has to come from a sector which already has a projected deficit of £2.8 billion. It seems that the Government are simply moving around the deficit deck-chairs on the “Titanic”. This is being done while the demand for efficiencies on the part of the CQC are marginal. It therefore follows that we should ask whether the regulator is giving good value for money and whether it is moving fast enough.
I wonder why the Government have chosen to ignore the overwhelming view of providers in the consultation, as the noble Lord, Lord Hunt, mentioned—the so-called consultation, perhaps I should say—given that the consultation on the proposed action was done before the CQC had completed and published its five-year strategy. As the strategy is expected to include significant changes to the inspection model, and therefore the costs, surely it should have been done the other way round.
Has any consideration been given to the idea of a risk-based approach to regulation, such as the one used by Ofsted, where schools that are consistently showing excellent results have a more light-touch inspection regime? Obviously, there would have to be safeguards and triggers for snap inspections, but it seems to work reasonably well in education so why not in health? It saves a lot of time and money.
There are a lot of questions there for the Minister.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, I first acknowledge the fact that any increase in fees, at a time when providers of adult social care, the NHS and elsewhere are going through a very tough time, is clearly very unwelcome. So perhaps it was not surprising, in a sense, that in the consultation when given the choice of spreading the increase over four years or two years, everyone voted for four years rather than two. I think everyone knows that, over time, it was the intention of the previous Government, as well as this one, to have full cost recovery. In the end, that must be right, but it is a question of how long it takes to get from where we are to where we need to be.
Most people will understand why the scope of the CQC’s work has developed over the past three or four years. The origins of the new CQC lay in what happened in Mid Staffordshire, Morecambe Bay and Winterbourne View, and a feeling that those tragedies could not be allowed to happen again. A much more comprehensive, expert-led inspection regime was the right way to try to unearth those awful things.
I totally understand what has been said by my noble friend Lord Lindsay and the noble Baroness, Lady Walmsley, about moving towards a more risk-based form of inspection. In the CQC’s strategy, which will be announced in a week or so, I hope there will be some reference to it having a more risk-based inspection regime. Of course, that has to be based, as my noble friend Lord Lindsay mentioned, on good intelligence. Over the past three years, the CQC has been able to collect intelligence, particularly on NHS trusts, where there are much better data—we are also using soft data as well as hard data—and that does enable one to put in place a more risk-based system of inspection. It has already said that it will re-inspect institutions that have a “Good” or “Outstanding” rating after a longer period of time than the ones with “Requires improvement” or “Inadequate”. But we will see when it produces its strategy next week exactly what it is planning to do.
On the comments of my noble friend Lord Lindsay, we did have some discussions when I was at the CQC, but I have to accept that they did not get very far. However, I would encourage him to meet the new chairman of the CQC, Peter Wyman, as well as David Behan, whom he already knows, to see whether or not there is any way that UKAS accreditation can help not just in adult social care but in aspects of clinical care as well.
On the points made by the noble Lord, Lord Hunt, about the consultation, the consultation period did go from 21 December 2015 to 1 February 2016. There was a reasonable period of consultation, but I accept that the implementation of the increase was much quicker. I also know that, although it did not sound very much in the context of the whole, for individual trusts this was just another cost increase that they had to bear. It is worth noting that the total cost of the CQC as a proportion of the whole that is expected for adult social care and the NHS is around 0.19%—very similar to the cost of Ofsted in education. So it is not as though it is expensive; it is just that the level of cost recovery has been ordained to be over a shorter time.
It is also worth noting that, for domiciliary care, the period of time is over four years and not two years. For GPs, where it was felt that the cost increase was the straw that might break the camel’s back, the baseline funding has been increased to allow for the extra increase.
Baroness Walmsley
My Lords, am I right in thinking that the help for GPs will be over just one year?
Lord Prior of Brampton
I believe that it has gone into the baseline funding of the GP contract, but if I am wrong about that I shall write to the noble Baroness.
More generally, the CQC’s scope and the way that it does its inspections is just much broader than it used to be. They are done in more depth and detail. This statutory instrument was introduced to Parliament so that it would reflect what the CQC is now doing and recognise its enlarged scope. The regulations do not extend the remit of the CQC’s activity or the scope of reviews or performance assessments to additional providers or services; neither does it change the fees actually charged.
The CQC, like every other aspect of the NHS, is going to have to save a considerable amount of money over the next five years, which the noble Lord, Lord Hunt, referred to in his speech. This means that the kind of inspections which we have seen in some NHS trusts, where a large number of very expensive people descend upon a trust, will have to be scaled back to some extent. As the noble Baroness intimated, I think that we will see a more risk-based inspection model—a bit more like the Ofsted model. I suspect that we will see more unannounced inspections as well, because a large part of the cost of the CQC is not just its direct cost but the indirect costs on the trusts preparing for the inspections. Sometimes the degree of preparation undermines the validity and insightfulness of the actual inspection.
I take on board entirely the strictures of the noble Lord, Lord Hunt. This is another expense when times are extremely hard, but it reflects the fact that the scope of the CQC is now broader than it was three years ago, and the need to have full cost recovery over a fairly limited time.
Junior Doctors: Contract
Baroness Walmsley Excerpts(8 years, 7 months ago)
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Lord Prior of Brampton
My Lords, given that we have the opportunity over the next five days to try to find a resolution to this dispute, it is probably not helpful now to talk about the “what ifs”. My experience of these situations is, the least said in public, the soonest mended. If the noble Baroness does not mind, I will not answer her question directly today.
Baroness Walmsley (LD)
Does the Minister accept that what he has said this morning, welcome thought it may be, is really rather too late? Trust is the most important element when it comes to the provision of medical services. The Secretary of State has already lost the trust not only of junior doctors but of a very large percentage of the general public. It has to be said that the BMA has also lost the trust of a certain percentage of the public. Trust is also important in political matters. We all accept the Government’s intention in their manifesto to provide more services seven days a week—of course, most junior doctors work seven days a week anyway—but does the Minister accept that imposing this contract at the end of the pause period is not the only way of achieving the Government’s objective? Further discussions with those who provide the services may very well find an even better way of providing these seven-day services to patients.
Lord Prior of Brampton
My Lords, I am not sure where that question ended up, to be honest. All I will say for today is that we have an opportunity over the next five days for the BMA and the Government to find a resolution to this issue. If we can, it will make the implementation of seven-day working across the NHS much easier.
Health: Hepatitis C
Baroness Walmsley Excerpts(8 years, 7 months ago)
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Lord Prior of Brampton
My Lords, there are many people who suffer from hepatitis C who are asymptomatic and do not know that they have hepatitis C, so I do not know if the figure of 220,000 is true or not. But people with it can have treatment using the drug interferon—which is an extremely unpleasant treatment that can take up to a year and has some very horrible side effects. This new drug is, in many ways, a miracle drug. It is a fantastic drug, but it is incredibly expensive. We have to accept that, not just for hepatitis C but for many cancer treatments, there are going to be some drugs that are too expensive to spend on huge numbers of people.
Baroness Walmsley (LD)
My Lords, if there are budgetary constraints, surely those victims who were infected by state action should have priority. Is the Minister aware that there are many Welsh patients who were infected with contaminated blood in English hospitals and are now being used in a game of pass the parcel between the UK Government and the Welsh Government? Can he say what was agreed at the meeting on 24 March between his officials and officials of the Welsh Government? Patients in Wales have not been able to get an answer from the acting Chief Medical Officer of the Welsh Government on this. Perhaps he could write to me.
Lord Prior of Brampton
My Lords, this new drug for hepatitis C is made available on the basis of clinical need, not the route of infection. There is a consultation going on about whether a special fund might be established for those who have received infected blood. I cannot answer specifically on the issue of the Welsh people but I will write to the noble Baroness on that matter.
Healthwatch England
Baroness Walmsley Excerpts(8 years, 7 months ago)
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Lord Prior of Brampton
My Lords, I should make it clear that the advert said that someone with a private sector background was desirable, not essential. No one else on the committee of Healthwatch England has a private sector background, so to have that kind of mix would seem common sense to me. Maybe it is particularly the case in that role, following someone such as Anna Bradley, who is very much a champion of consumers. Having that sort of championship of consumers on the board of Healthwatch England is important. With regard to the line of responsibility of the chair of the CQC, she is still ultimately appointed by the Secretary of State for Health.
Baroness Walmsley (LD)
My Lords, what precisely is it that somebody with a private sector background could bring to this organisation that somebody without a public or voluntary sector background would not bring? Should not the criteria be much more about understanding how best to undertake public engagement and an ability to shape services that reflect public priorities and concerns? Does this Question not raise a more general one about the politicisation of public appointments?
Lord Prior of Brampton
I disagree. I had a private sector background when I became chairman of the CQC, I might add, so perhaps I am slightly biased in this regard. Having a mix of people from all different backgrounds, whether private, public or voluntary sector, is a very good thing.
Junior Doctors: Industrial Action
Baroness Walmsley Excerpts(8 years, 7 months ago)
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Lord Hunt of Kings Heath (Lab)
First, my Lords, I thank the noble Lord for repeating the Statement made in the other place. No one could be in any doubt that tomorrow’s strike will be a very sad day indeed for the NHS and the country. What is so frustrating is that it could, I am convinced, have been prevented. Yesterday the Health Secretary was presented with a genuine and constructive cross-party proposal to pilot the contract and potentially avert this week’s strike. A responsible Health Secretary would have grasped the opportunity immediately or would at least have considered and discussed it. However, all we had was a tweet yesterday morning from the Health Secretary saying, “Labour ‘plan’ is opportunism”. That was a deeply disappointing response.
The proposal was not a Labour plan. It was co-signed by two respected former Ministers, the Conservative Member for Central Suffolk and North Ipswich, and the Liberal Democrat Member for North Norfolk, as well as the SNP’s health spokesperson, the honourable lady the Member for Central Ayrshire. It not only had the support of a number of medical royal colleges, including the Royal College of Surgeons, but, crucially, the BMA had indicated that it was prepared to meet with the Government and discuss calling off Tuesday’s and Wednesday’s action.
The Health Secretary has claimed that a “phased imposition” is the same as a pilot, but can the Minister explain how imposition on a predetermined timescale, with no opportunity to make changes to the proposed contract and no independent evaluation of the impact on patient care, can be the same as a pilot? Surely the Health Secretary should have welcomed independent evaluation. Surely he wants to know how changing this contract contributes in practice to his aspirations for more consistent emergency care across seven days of the week. And surely there was always a strong case for road testing the contract, thus enabling junior hospital doctors and managers in those hospitals to bring about changes in patient care and the outcomes that the Government want to see. The Government claim that any further delay will mean that it will take longer to eliminate the so-called “weekend effect”, but he has failed so far to produce any convincing evidence to show how changing the junior doctors’ contract by itself will deliver that aim.
On safety, NHS England’s update today says that the NHS is pulling out all the stops to minimise the risks to the quality and safety of care. We know that in many cases senior clinical staff will be stepping in to provide cover and ensure the provision of essential services. But there is no escaping the fact that this is a time of unprecedented risk, as regards what happens not just in the next two days but in the months and years ahead.
So can the Minister say how it will be safe to impose a contract when no one knows what the impact will be on recruitment and retention and when everyone in the service fears the worst? How can it be safe when we are running the risk of losing hundreds of women doctors, given the contract’s disproportionate impact on women—which, as the Minister knows, was disclosed by the belated publication of the equality assessment? How can it be safe to impose a contract that risks destroying the morale of junior doctors and to introduce a contract where there is no guarantee that effective and robust safeguards will be in place to control hours worked and shift patterns?
I noted that the Statement made some rather eloquent or exaggerated claims about the amount of money going into the NHS. I do not want to distract our focus from the essential point in question, but I point out to the Minister that we are on the longest period when the amount of real-terms growth going into the NHS has been less than 1% per annum, against an average increase since 1948 of 4% per annum. Our share of GDP spent on health is going back down to the days in the mid-1990s when we were spending about 6% of GDP. When you compare that to the demands being placed on the health service and the workforce demands that the new contract entails, it is very difficult to see how you can square the ambitions of the Secretary of State on the one hand and the practical reality of what resource has been made available.
Even at this late hour—and it is later than when the other place debated this Statement—I hope that sense will be seen and that the Government will recognise that there is a need to come back to the table to discuss not just the contract but the wider issues of the disengagement of the junior doctors, their concerns about the current approach to training, the fear that the imposition of this contract will lead to less well-trained doctors in the future, and indeed the issues around workforce and women doctors which have now been identified but on which I have yet to hear a convincing response from the Government. Even now, the case for getting round the table with the junior doctors is persuasive.
Baroness Walmsley (LD)
My Lords, instead of reeling off the litany of justifications and figures that we have just heard, is it not really time for the Secretary of State to put aside his pride, stop being pig-headed and listen to people in the national interest? He is clearly not listening to the junior doctors but will he not now listen to the sensible compromise proposal from other parties, including my own, which, I point out, does not undermine the Government’s objectives in the long term?
There are two big differences between the euphemistic “gradual introduction” that he is proposing and the pilot projects proposed by other parties. The first is that of course a pilot scheme can be independently evaluated. If the Secretary of State is so confident that this scheme will not damage patients or doctors, why is he afraid of proper evaluation? The proper and safe implementation of the new contract is surely worth a very small delay. Secondly, a pilot would mean that all junior doctors evaluated in a hospital would be on the same contract, whereas piecemeal introduction, which he is proposing, could mean that two doctors working side by side in the same department were on totally different contracts. Does the Minister not agree that this would be deeply divisive, as well as very difficult practically?
I am also very concerned about the idea of consultants manning A&E departments this week. While I am grateful to them for being willing to step forward in the interests of patient safety, I am concerned that it might work in the opposite direction in their own departments. Who will take the difficult decisions in, for example, cardiology or vascular medicine when urgent cases come up and the consultant is setting somebody’s broken finger in A&E? Has the Minister thought about that?
Should not the Secretary of State consider his position? Is he really the right person to solve this dispute? Patient safety, not the future of his own job, should be his prime consideration. This week, that will be at risk—website or no website.
Lord Prior of Brampton
My Lords, I am personally massively sympathetic to the concerns expressed to me by many junior doctors over the last three or four months, and in fact over the last 12 or 13 years. For family and personal reasons, too, I feel hugely in sympathy with the situation in which they find themselves. There is no doubt that the training of junior doctors is wholly inadequate. Their placements are short term and they move from one rota to another, with many rotas unfilled. There is a lack of teamwork now that the old firm has gone and nothing has replaced it. There is also a lack of leadership and mentorship for juniors.
When I compare the training and TLC that junior doctors get with that received by those going into accounting, law, big corporates, investment banking or other areas like that, I think that the lot of the junior doctor is not a good one. I remember reading a paper, probably 10 years ago, by Dame Carol Black when she was president of the Royal College of Physicians. She talked about the deprofessionalisation of the profession, and that really will come to pass if we are not careful. So I am hugely in sympathy with many of these issues and I have particular sympathy for women—especially young women with families and so on.
But let us be honest about this. That is not what this contractual dispute is about. Those are the big issues but this dispute is about pay on Saturdays. That is the issue that the contract fell down on. The noble Lord and the noble Baroness opposite talked about a pilot—but are we really talking about piloting a different Saturday pay structure? Everything else was agreed between the BMA and Sir David Dalton. To be honest, it is disingenuous to say that we could pilot something like that. Fundamentally, this is about pay, and I think that the junior doctors have got it wrong when they go on strike and withdraw emergency cover over an issue related to premium pay on Saturdays. It is simply not a big enough issue to cross the threshold of withdrawing emergency cover. They must recognise that. There will be a time to address the more fundamental issues affecting the training of junior doctors, and they must be addressed for the sake of the profession, of patients and of hospitals—but, sadly, that is not the issue that we are confronting today.
Two other important issues were raised. In answer to the noble Baroness, not all cardiologists and cardiac surgeons are rushing off to an A&E department. They will cover urgent and emergency cases in their own specialties as well.
Although in a way it is not for debate today, the noble Lord, Lord Hunt, raised the very fundamental, long-term problem of whether there are the resources within the system to deliver the ambitions that we all have for a world-class health service. Maybe today is not the time to answer that: we should probably focus on the matter in hand.
NHS: New Junior Doctor Contract
Baroness Walmsley Excerpts(8 years, 8 months ago)
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Lord Prior of Brampton
My Lords, the noble Lord has raised two substantial points. The first is the difference between introduction and imposition. The fact is that, in the context of the NHS, where there is really only one offer, the difference between introduction and imposition is very small. Technically, it is true that individual employers are responsible for its imposition, but in reality, as the noble Lord will know from all his years in the Department of Health, the Secretary of State has considerable powers in this matter. I do not think the noble Lord would want all trusts to cut their own deals locally—there has to be an actual contract. It is true that when the legislation for foundation trusts was brought forward by the noble Lord’s Government a few years ago, they were given the power to negotiate their terms and conditions locally but, with the exceptions of, I think, Southend and possibly Guy’s and St Thomas’, they have chosen to stick with the national contract.
On the noble Lord’s last point about a way through, there are no winners from this dispute. The patients are very clear losers, and it is tragic that we have got to the situation that we have. The threshold for withdrawing emergency cover from hospitals needs to be a lot higher than the one the junior doctors are adopting on this occasion.
Baroness Walmsley (LD)
My Lords, this Statement comes at a time when the latest figures for A&E performance are the worst ever—1% lower, we were told last week, than the figure for January, which was the previous worst ever. The staff are very close to exhaustion. Thirty-five per cent of the doctors in this country were born abroad—the highest level in the OECD. With this very long-running dispute, many junior doctors are now saying that they are going to go abroad, and the Government have not told us whether they will increase the number of places for trainee doctors to try to compensate for that. We, and the doctors themselves, really need to know.
I would also like the BMA to tell us what percentage of its members now want to strike, because I think that it has given us old figures. However, if the Government want a seven-day NHS, this is absolutely the wrong time to target the junior doctors. They need to do some proper negotiation and not hold the sword of Damocles over the heads of some of the most important public servants we have.
Lord Prior of Brampton
My Lords, the noble Baroness talks about a proper negotiation. This negotiation has gone on for three years and there have been 75 meetings about this contract. It is hard to know what a proper negotiation is when you have that number of meetings over that period of time. The junior doctors may not recognise this but the Government feel that 73 different concessions were made during that period. In many ways this has gone on for too long, and that is why, when Sir David Dalton got involved towards the end of the contract negotiations, his advice was, “You’ve got to settle this”. We cannot go on and on negotiating and discussing these matters.
On the other point that the noble Baroness raised, the pressure on our emergency services is huge at the moment. She is right that the A&E performance in January was very poor, but it is simply the case that demand on our A&E departments is huge.
E-cigarettes: Regulation
Baroness Walmsley Excerpts(8 years, 9 months ago)
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Lord Prior of Brampton
I also congratulate the noble Lord on giving up cigarettes and taking up these other products. I do not know whether he has tried unicorn blood or crab leg flavours, but a multitude of flavours is available on the market. The directive has come about purely because of the feeling that although nicotine is better than smoking, it is not perfect.
Baroness Walmsley (LD)
My Lords, although these products are clearly much less harmful than smoking tobacco, they are not entirely harmless. They have a lot of noxious chemicals in them. What are the Government doing to inform people about the research on the potential hazards of these products, including the reduction in resistance to infections, reduction in fertility and changes in behaviour patterns?
Lord Prior of Brampton
My Lords, as I said, these new products are not perfect but are substantially better than smoking cigarettes. One of the purposes of the new directive is that there should be proper labelling on the products.
Pharmacies: Funding
Baroness Walmsley Excerpts(8 years, 9 months ago)
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Baroness Walmsley
To ask Her Majesty’s Government what steps they will take to ensure that every community continues to be served by a local pharmacy, in the light of their plans to cut funding to pharmacies in October.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, community pharmacies are a vital part of the NHS. The Government believe efficiencies can be made without compromising the quality of services or public access to them. Our aim is to ensure that community pharmacies upon which people depend continue to thrive. We are consulting on a pharmacy access scheme which will provide more NHS funds to certain pharmacies compared to others, considering factors such as location and the health needs of the local population.
Baroness Walmsley (LD)
I thank the Minister for his reply. Has he made any assessment of the value of the services provided by pharmacies to the NHS, local communities and local authorities in assisting with their public health responsibilities? In light of the importance of all these services and the potential for expansion in future, is it not rather arbitrary of the Government to make these cuts that I understand could cause the closure of 3,000 pharmacies? Then they will sit back and wait for the survival of the economic fittest.
Lord Prior of Brampton
My Lords, it is important that we recognise the fundamental changes happening in the market that community pharmacies operate in. With the growth of online ordering of prescriptions, the large-scale automation of dispensing and the integration of health services within which community pharmacies are absolutely vital, the industry will have to change.
National Health Service: Workforce Race Equality Standard
Baroness Walmsley Excerpts(8 years, 9 months ago)
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Lord Prior of Brampton
My Lords, the whole purpose of the WRES is to shine a light on the performance of each trust in the country. The CQC will be including it in its well-led domain from March of this year and has already begun to incorporate it into its inspection processes. As the noble Lord knows, in Bradford where he is the chairman of a trust, we have a huge amount of progress to make.
Baroness Walmsley (LD)
My Lords, what is being done to ensure fair career progression further down the ladder? Unless we get people moving up, we will never have BME medical directors. Further, is he prepared to comment on diversity among the personnel in the recruitment agencies themselves that work for the NHS?
Lord Prior of Brampton
My Lords, the noble Baroness makes a good point. In a way the WRES focuses very much on the more senior grades in the NHS, but we need to focus on progression from band 4 into 5 and 6 as well. It is an important point that needs to be taken on board. As far as recruitment is concerned, it is very important that we have people from BME backgrounds on the recruitment panels. Getting the right people is crucial, and if that means going to external recruitment agencies when we have to, we should not rule that out.
Accident and Emergency Services: Staffing
Baroness Walmsley Excerpts(8 years, 9 months ago)
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Lord Prior of Brampton
My Lords, seven-day working clearly goes far beyond junior doctors; it requires senior doctors, pharmacists, social workers, and primary care as well as acute care if we are to deliver a full seven-day service. As my noble friend knows, that is our objective over the next five years.
Baroness Walmsley (LD)
My Lords, does the Minister endorse the principle of Kirsty Williams’s Private Member’s Bill in the Welsh Assembly, the Safe Nurse Staffing Levels (Wales) Bill, which, having passed with all-party support, now ensures safe staffing levels in all wards in Wales? Will the UK Government follow the example of the Liberal Democrats in Wales?
Lord Prior of Brampton
My Lords, I can perhaps be excused for not following all that carefully Private Members’ Bills in the Welsh Assembly promoted by the Liberal Democrats. Safe staffing is obviously very important. I quote Mike Richards on this, who says that it is,
“important to look at staffing in a flexible way which is focused on the quality of care, patient safety and efficiency rather than just numbers and ratios of staff”.
That is extremely important.