NHS: Abuse of Nurses

Baroness Watkins of Tavistock Excerpts

Tuesday 5th April 2022 Lords Chamber

[Lord Kamall (Con)]

The noble Lord is absolutely right that we have identified the issue, and the NHS is working on a number of plans. All of us abhor any abuse of nurses or indeed any other NHS staff. The NHS has looked into this and has seen that many cases of violence against NHS staff are committed by individuals who are in a mental health crisis, or suffering from dementia or other neurological conditions, rather than the classic perception of attacks on staff by the public. The NHS has not only the violence prevention and reduction programme but a number of other initiatives to try to tackle this unwarranted issue.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interests as outlined in the register. I particularly want to raise the issue of nurses on shifts who are having difficulty parking both near the hospital for a reasonable cost—that cost was removed during Covid, which made life much easier for them—and in the community, where we have reports of them being abused for parking near patients’ homes. What strategy will the Government achieve to reduce this stress and the associated verbal violence?

Ockenden Report

Baroness Watkins of Tavistock Excerpts

Wednesday 30th March 2022 Lords Chamber

[Lord Kamall (Con)]

I begin by thanking the noble Baroness, Lady Finlay, not only for her questions today but for the advice she has given me over a number of months since I started in this post. I have learned so much from the noble Baroness, especially from her courage to speak about her own professional experiences and admit where there are issues that need to be addressed. I am very grateful for that.

I completely take the point about working together from day one because, if you do that, you embed that culture of collaboration from day one, rather than just training people and then saying, “Oh, by the way, don’t forget to work collaboratively”. I think that has to be bred into the system and it is something we have to understand.

The other principle, which all noble Lords discussed in debates on the Bill, is the concept of a safe space. In an ideal world, we would find out who was responsible and they would be held to account, but what is really important is that we learn from that and the system learns from its failures. We have to encourage the ability to have a safe space where people feel confident about speaking up. We saw incidents where people felt bullied into not speaking up or where they withdrew their statements. If we can get this through the SHA and throughout the culture of the new HSSIB, this would be a really important first step. I thank noble Lords who, during the debate, pushed for the removal of certain bodies in order to make sure people felt comfortable coming forward.

On the CQC, there are real questions about the inspections in 2014 and 2016 and why it did not recognise safety concerns at the trust. Subsequently, the CQC did recognise the issues and place the trust in special measures. There was some progress made by the trust following this, and there were two subsequent visits. As a regulator, the CQC holds providers to account and makes clear where improvements must be made, but I think it recognises that there are lessons to be learned. There are lessons to be learned not only in government but across the health and care sector. It is important that we look systemically at how we work together and address some of those concerns.

[Baroness Watkins of Tavistock (CB)]

My Lords, I also thank the Minister for the sensitive way in which he has addressed this very difficult statement.

I was particularly moved by the fact that there are empty bedrooms. I have a daughter who is 31. I took a long time to get pregnant and, at the very end of my pregnancy, I woke up and said that I was ill. I went to hospital and my husband said to me, “I don’t think you’re ill, I just think you’ve never had a baby before”. But as the day went on, he came to see me, and apparently I said to him, “If anything happens to me, you will look after our child, won’t you?” He said it frightened him because I am not given to drama. He went to the midwife in charge of the ward and said, “I’m really worried about my wife”. It was taken seriously. I had a scan, and—the noble Baroness, Lady Finlay, will know that this is very rare—I had a rare form of pre-eclampsia in my liver, called HELLP syndrome. In 10 minutes, I had a caesarean section. I was ill for several months and my daughter was in ITU. She has a bedroom at home—she does not live in it except when she comes back—and it has really made me think, not just about the women who lost families but about how much we train healthcare professionals to listen to the significant other of the person. We have not said a lot about that today. That significant other may be a husband, it may be a man, it may be a same- sex partner, but I urge that training includes listening to the significant other.

I also want to raise that strengthening clinical reporting at board level is essential. I and others did research after the Francis report, where it was very clear that boards were not spending significant time looking at clinical issues but were looking at financial issues. That changed then, but I believe the Ockenden report reminds us that there should be further NHS guidance to boards about their responsibility for examining mortality and morbidity rates in order that that is kept closely under supervision at board level. Believe you me, as an ex-deputy chair of a trust, I know that that was one of the most important things I looked at. I chaired the clinical audit committee and I know that those are the things that can pick up recurring issues early and enable boards to look at what is actually going on in the system. We do not want to have another Ockenden report that may not be about midwifery but about something else.

My final issue is to re-emphasise that we must get workforce planning right for the whole of the NHS, not just midwifery—though I welcome everything the Minister has said in relation to midwives and obstetricians.

[Lord Kamall (Con)]

I thank the noble Baroness, Lady Watkins, for sharing a very personal story. It must have taken quite a bit of courage to share that with us so publicly.

The noble Baroness talked about the “significant other”. Sometimes we consider ourselves the insignificant other. I remember when I became a father about 20 years ago for the first time. When you watched the TV programmes, they quite often told the father, “Go and have a smoke and come back. We’ll let you know.” Clearly, nowadays, you would not advise anyone to go and have a smoke. I remember how involved I was allowed to be. I was in the room for 22 hours for the first birth. Pre-natal care was fantastic, but once the baby was born, my wife was ushered into a bathroom, and I was sent away somewhere else. I could hear her voice. She called me. When I went in, she was sinking into the bath; she was just too exhausted. She was terrified and did not have the strength, and I pulled her out. It might have been a tragedy—I do not know—but it shows that even little things like that could have made a huge difference.

We are all grateful when a wonderful new life comes into this world. Let us think about the preparation that families go through—they prepare a separate room; families buy baby clothes and toys for everyone, expecting that bundle of joy to come home. When that is cruelly snatched away from them due to incompetence, we have to make sure that it happens as little as possible in the future. We know that incidents will occur. It brings a lump to the throat.

Noble Lords will recognise that there has been a debate on workforce. There is a debate in government on it. We shall just have to see how that resolves itself. I have heard loud and clear from noble Lords that it is not only about the maternity workforce; it is also about the wider NHS workforce, as well as making sure that we learn from incidents like this and build in that culture of prevention but also openness when things go wrong.

Health and Care Bill

Baroness Watkins of Tavistock Excerpts

Lords Hansard - Part 2 & Report stage
Wednesday 16th March 2022 Lords Chamber

The concerns that I and others have about this kind of at-home early medical abortion are not sufficiently mitigated by the amendment, and in-person visits to a clinic or medical centre continue to be vital. Supporting the vulnerable and creating thorough and effective legislation to do so must be our priority, hence my opposition to the amendment. I conclude by repeating my honouring of the noble Baroness, Lady Sugg.

[Baroness Watkins of Tavistock (CB)]

My Lords, I support this amendment, to which I have added my name. Evidence-based practice that utilises modern technology for the assessment and delivery of treatment for people who choose to take the first pill at home is cost-effective. I think we forget that the majority of healthcare workers, be they medics, midwives or nurses, try to provide person-centred care. Person-centred care means that some women will still be asked to come into the clinic to take that tablet because it is the best solution for that woman.

However, some women live in rural environments where there are very poor bus services. When I went to the women’s meeting at the UN three years ago with other Members of this House, young women representing the four country youth parliaments told harrowing tales of women who had been given the tablet in a clinic but had not got home before the spontaneous abortion commenced. We heard very good examples, particularly from some other countries in Europe, where taking the tablets at home was already normal practice.

The largest study on telemedical abortion in the world was conducted in the UK, covering 52,000 women both before and after the change—in other words, using the natural experiment that occurred as a result of lockdown. There was no change in adverse incidents, no change in successful completion rates, a reduction in waiting times, a reduction in gestation at treatment and it was preferred by women. This evidence was used by the US Food and Drug Administration to make the first tablet at home a permanent option at the end of last year. As the noble Baroness, Lady Sugg, has just said, the World Health Organization issued its international Abortion Care Guideline last week. Telemedicine and self-management of abortion outside a healthcare facility are both in there.

This amendment would enable better person-centred care for the majority of women, as well as for their families and often their partner who will be with them at the time—particularly for people who are perhaps having a third or fourth child which for clinical reasons is not advised. I therefore hope that the fact the majority of people here have a free vote means that they really consider what I have just said.

[Baroness Eaton (Con)]

My Lords, health and safety have arguably never been more front and centre in our nation’s thinking and approach to healthcare. The Government prioritising healthcare in one of their flagship Bills is therefore expected. I am proud of our Government.

As proud as I am, I feel equally perplexed as to why the amendment tabled by the noble Baroness, Lady Sugg, seeking to override the Government’s decision to end the temporary policy on at-home abortion would garner any serious consideration, given that it would contradict the aims of the Health and Care Bill by placing the health and safety of women and girls at risk. It also distracts from important matters in the Bill, for which the Bill was intended.

The provision allowing at-home abortion made alongside a host of other Covid regulations during an unprecedented global crisis was only ever meant to be temporary alongside almost all other temporary provisions of the Coronavirus Act that the Government are expiring or have already expired. The Prime Minister said that the Covid restrictions

“take a heavy toll on our economy, our society, our mental wellbeing and the life chances of our children”.—[Official Report, Commons, 21/2/22; col. 45.]


The health toll could not, in the specific case of the temporary provision allowing at-home abortion, be more apparent; it is a toll being taken on vulnerable women and girls. As highlighted by a submission to the government consultation on this matter, the lack of in-person consultation increases risks of potentially life-threatening conditions being missed, pills being prescribed beyond the 10-week limit, more women being coerced into a home abortion against their wishes and pills being obtained fraudulently.

These are not unwarranted concerns. Soon after the temporary policy was implemented, story after story emerged of the tragically painful experiences women underwent as a result of this policy. For example, a Telegraph article reported on a nurse whose at-home abortion led to extreme complications needing surgery. Indeed, there have been several cases of women taking these abortion pills outside the legal and safe time limit. For example, in May 2020 police investigated the death of an unborn baby after a woman took pills received by post at 28 weeks pregnant. Such cases are unsurprising given that abortion providers cannot ensure that at-home abortion pills are taken by the intended person in the intended circumstances and time. According to the American College of Obstetricians and Gynecologists, only half of women accurately recall their last menstrual period, again reaffirming that medical confirmation of gestational period is critical.

Given the vast evidence base highlighting how this policy has placed women’s health and safety at risk, an evidence base thoroughly reviewed by the Government in an extensive three-month consultation, I urge the noble Baroness, Lady Sugg, to withdraw her amendment but if she does not, I urge noble Lords to vote against it.

Health and Care Bill

Baroness Watkins of Tavistock Excerpts

Lords Hansard - Part 1 & Report stage
Thursday 3rd March 2022 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I rise briefly to support this group of amendments and to declare my interest as a fellow of the Royal College of Nursing. It is absolutely clear to me that, without the right staff in the right place, you cannot give the right care. This is the situation we are in at the moment, and we must get it right for the future. We are on an improvement trajectory, and there is an increase in the number of nurses employed in the NHS. However, this is not universal across all areas of the NHS, particularly in learning disability and mental health.

If we could get the Government to support Amendment 80, we could resolve the issue through guidance. On Amendment 81, I also speak for my noble friend Lord Patel, who unfortunately cannot be here today and who believes that an elegant solution as described by my noble friend Baroness Finlay, in terms of guidance subsuming Amendment 82 in particular, would enable directors of nursing, medicine and care to be responsible for ensuring that they have a safe staffing structure in the areas for which they commission care. That would be reported up every two years through the Secretary of State, rather than every five years, as indicated in Amendment 82. This would be a much more suitable solution.

[Lord Lansley (Con)]

My Lords, I will intervene. I was not intending to speak but I was prompted by a recollection arising from the reference to anaesthetists by the noble Baroness, Lady Finlay. I recall that the Centre for Workforce Intelligence produced in February 2015 a report on the future supply and demand of anaesthetists and the intensive care medicine workforce. I have just checked the report, and it projects for 2033 that the number of full-time equivalent staff required will be 11,800, and supply will be 8,000. Therefore, in February 2015, we knew of this set of projections produced by the CWI. It said, among other things, that there should be

“a further review in the next two to three years.”

However, the CWI was abolished in 2016 and its functions were restored, I think, to the Department of Health.

The noble Lord, Lord Stevens, did not refer to this directly, but we must bear in mind the general presumption that there has never been workforce planning, although in certain respects, there has. The report on anaesthetists is only one of a whole string of reports—I could list them, but I do not need to—produced by the Centre for Workforce Intelligence before it was abolished. Their main purpose was to say to Health Education England, “This is the level of education and training commissioning you should be undertaking in the years ahead”. As the noble Lord said in Committee, it did produce a set of proposals; it is just that they were not acted upon.

I just say this: legislation may be the right way to proceed now, but let us not lose sight of what is actually required, which is for Health Education England not to have its budget cut, as happened in 2016, but to have its budget increased and for that budget to be turned into an education and training commissioning programme that delivers the numbers of trained professionals in this country that we project we will need. It is no good saying, “Oh, we’ve never had planning; we passed a piece of legislation.” I am sorry, it could be a case of legislate and forget unless the money is provided and the commissioning happens. There have been organisations whose job it was to do it—Health Education England, the Centre for Workforce Intelligence—but they were not supported, and in one case, abolished.

Health and Care Bill

Baroness Watkins of Tavistock Excerpts

Lords Hansard - Part 1 & Report stage
Tuesday 1st March 2022 Lords Chamber

[Lord Shipley (LD)]

My Lords, now that we are on Report, I must remind the House that I am a vice-president of the Local Government Association.

I rise to speak to Amendments 63, 65 and 67 in this group, to which I am a signatory along with the noble Baroness, Lady Armstrong of Hill Top. I will not repeat the points made in Committee and this afternoon unnecessarily because I am confident that the Government are listening to what has been said and wish to see progress towards levelling up health outcomes and tackling health inequalities. It is the right thing to do.

I lend my support to three policy solutions in particular. The first is the significant opportunity presented by the forthcoming health disparities White Paper. The Government should not miss the opportunity that this presents because it can clearly set out how exactly they propose to lead on tackling the poor health outcomes of inclusion health populations. I hope that the Minister will work closely with the voluntary and inclusion health sectors to shape what the White Paper will say. Secondly, I support the idea of creating a task force from the Department of Health and Social Care and NHS England to help drive forward the Government’s work to reduce health inequalities for the most marginalised. Thirdly, I urge the Government to take this opportunity to update guidance to specify explicitly that the NHS does not exist in a vacuum and that secure, safe housing is critical to an individual’s health and well-being. I hope that the Minister will be able to confirm that statutory guidance and the White Paper will reflect all these matters.

Having said that, these three amendments—Amendments 63, 65 and 67—are still important. I welcome yesterday’s letter from the Minister, the noble Lord, Lord Kamall, explaining the package of government amendments now also proposed. I am pleased that that letter confirmed the Government’s commitment to tackling health inequalities. It is very positive to see the reference to “persons”, not just “patients”, in Amendment 3 as an important statement of principle both for inclusion health and to improve outreach, as the noble Earl, Lord Howe, said earlier.

Progress has been made following Committee but I still seek reassurance from the Minister that the Government will dedicate the necessary time and resource to tackling the poor health outcomes of inclusion health populations, who can all too easily fall through the gaps in provision.

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to speak to this group of amendments. I declare my interest as chair of Look Ahead, a housing association that specialises in working with people with complex needs. I am delighted by the Government’s new amendments in this area—I believe that they go a long way—but I am disappointed that housing appears to have been omitted from the government amendments.

--- Later in debate ---

[Baroness Bennett of Manor Castle (GP)]

My Lords, I am delighted to contribute to this rich and important debate, and particularly to speak to Amendments 10 and 13 in my name.

Commenting on the words of the noble Baroness, Lady Meacher, about the importance of public health, I would stretch that much more broadly than the examples that she gave. It really ties to the previous group, where we were talking about how climate change and the nature of the environment are related to health. A public health approach really is talking about ensuring that we have a healthy environment, that we prevent illness and malfunction. If we do not have that approach in the ICBs, that is a real problem.

I agree with the noble Lord, Lord Bradley, that government Amendment 31 is useful but not sufficient to deal with the issues that are raised by this group of amendments. The Green group very much agrees with Amendments 9 and 12 and will support them should we get to that point.

I declare my interest as a vice-president of the LGA and the NALC, which may be relevant here. In speaking to Amendments 10 and 13, I declare exactly where I come from. It was the Royal College of Nursing that persuaded me that these amendments should be here. It is very much the college’s case that I now present.

To begin with a little bit of history, as part of the statutory regulations of the Health and Social Care Act 2012, it was mandated that registered nurses would be part of the governing body of clinical commissioning groups. If we look at Regulation 11 of the National Health Service (Clinical Commissioning Groups) Regulations 2012, we see that a CCG governing body must have at least one registered nurse within its membership. This will be lost if it is not required within the leadership of the integrated care boards.

This ties to a point made by the noble Lord, Lord Bradley, that sometimes there are very powerful forces in medicine. It also relates to the points made by the noble Baronesses, Lady Thornton and Lady Brinton, about the powerful force of private interests in medicine. Other truly important voices often get swept aside. It is worth noting that in the NHS in England, registered nurses are more than 49% of all professionally qualified clinical staff. They have a unique relationship with patients and clients which gives them a different insight to other professionals on how the service works, and in ensuring that measurement of performance reflects the interests of patients and clients.

In representative volume terms alone, the case here is very clear. Registered nurses lead, innovate, and deliver the largest proportion of care, and their leadership brings critical expertise, advice and challenge into boards. Without this clinical leadership, there is a risk that service design and delivery become a matter of financial accounting, without proper attention being given to quality and outcomes for patients and clients, or that there is a focus on the heroic interventions rather than on day-to-day care or on the importance of rehabilitation, on which we heard a lot of debate in Committee and which is an area to which our registered nurses bring particular skills.

It is not my intention to move these amendments, but I hope that the Government will listen to the case being put by what is a hugely important professional body and a hugely important body of professionals, and that we see action taken after this debate to make sure that registered nurses are represented.

[Baroness Watkins of Tavistock (CB)]

My Lords, I rise to speak to the amendments in my name and to support those of the noble Baroness, Lady Hollins, who earlier described the need to standardise the knowledge and experience of commissioners, given the potential significance of their decisions.

The Government rightly suggest that there must be some flexibility so that integrated care board membership best reflects the competences needed to commission for local populations. However, unless regulations stipulate essential criteria for members’ collective skills, knowledge and experience, we risk falling into old habits of medical paternalism. That will undermine efforts towards more integrated, holistic care and mental health needs may be given cursory regard. The voices of nurses—as so ably outlined by the noble Baroness, Lady Bennett of Manor Castle—and other professionals will not be heard.

I would like to share with the House a well-known quote in organisational management: “Every system is perfectly designed to get the result it gets”. We now have the opportunity to safeguard the diversity of experience in each integrated care board by establishing a minimum standard, imposed either by regulation or by statutory guidance, to ensure the system gets the result that best meets commissioners’ needs for local patients and populations across the country.

[Baroness Whitaker (Lab)]

My Lords, as well as supporting Amendments 9 and 12 and the rest of the group, I would like briefly to add my support for Amendment 31 in my capacity as patron of the British Stammering Association. This amendment is very much welcomed by the Royal College of Speech and Language Therapists, for all the reasons that we set out in Committee. It would do much to improve the expertise available for these damaging difficulties with the basic human need to communicate and the capacity to swallow, so I hope the Government adopt it—I am sure they will, because it is a government amendment. I am very grateful.

Health and Care Bill

Baroness Watkins of Tavistock Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 9th February 2022 Lords Chamber

[Lord Crisp (CB)]

My Lords, I would like to use one example to illustrate the importance of Amendment 291 in the name of my noble friend Lady Greengross, and her call for a dementia care plan. It relates to the second point: that the plan must recognise the different types of dementia and their specific care. It is also true that it needs to recognise the different groups of patients affected by dementia and their needs.

I am thinking from personal experience of people with Down’s syndrome. Noble Lords may know that something like 50% of people with Down’s syndrome who reach the age of 60 also have Alzheimer’s; there is some genetic connection between the two. However, the field of dementia has not really caught up with this yet. This is a developing field. The real importance of the plan that my noble friend advocates is that it constantly develops as knowledge develops about particular groups of patients and how they are affected.

The truth today is that patients such as the person I am thinking of are too often let down by the system, because too few clinicians understand the links between the two diseases and the particular needs of people with Down’s syndrome who also have Alzheimer’s.

[Baroness Watkins of Tavistock (CB)]

My Lords, I support the majority of these amendments, but I want to reflect on something that my noble friend Lady Greengross said about the lack of treatment for people with dementia. In fact, there are emerging treatments, and having had the benefit more than 40 years ago of working at a second referral unit at the Maudsley Hospital, I know that people who present with dementia so often also have quite severe depression at the beginning of recognising that they are losing some of their cognitive function. That can be treated very effectively and people can be enabled to live much happier lives for the first part of their care.

I want to give one other example. As a clinical nurse, I was called to help a unit that had severe problems. I do not think there was any maltreatment, but there was certainly a lack of competence in care in the place that I visited. There was a gentleman who was tall and extremely thin who, they told me, had two people with him all the time because he was so agitated. They could not get him to sit down to eat and his relatives did not want him to have any medication.

I am pleased to tell noble Lords that I got involved and we got a consultant psychiatrist in. The family were persuaded that a small amount of anti-psychotic medication might improve the quality of this man’s life. It did; his agitation significantly reduced and he was able to sit to eat. He lived for only another nine months, but those nine months were much happier than they would have been without that medication.

Although I firmly believe in all the social prescribing that we are talking about, we do not necessarily need a dementia care plan; we need a dementia care and treatment plan with an associated workforce development plan. Will the Minister seriously consider those issues?

Health and Care Bill

Baroness Watkins of Tavistock Excerpts

Lords Hansard - Part 2 & Committee stage
Monday 31st January 2022 Lords Chamber

[Baroness Greengross (CB)]

My Lords, I rise to speak to my Amendment 289, which would ensure that every hospital has sufficient accommodation to allow a bed for any patient who is rehabilitating and who no longer needs to be in hospital, but who cannot be discharged to their own home. Further, this amendment would place a duty on the Secretary of State to ensure that hospitals use any spare land owned by the NHS to build this accommodation.

For many years I have been an advocate for this type of accommodation. The NHS has struggled for a long time with a lack of available hospital beds, a situation made worse by the coronavirus pandemic. Having rehabilitation accommodation for people who need to be near a hospital in case they need to see a doctor, but who do not need the full services of an NHS hospital bed, which is considerably more expensive, would be of considerable benefit. In Scandinavia, patient accommodation of this nature has been part of the state health system since the late 1980s. Having patients stay in these facilities, which are designed to cater for people needing medical care, has delivered considerable savings to the public health system.

The cost of someone staying in one of these hotel rooms is less than a third of the cost of someone staying in a hospital bed. This is a great example of how the private sector, working in conjunction with the state, can enhance efficiency and deliver better public health outcomes. Over the last couple of years I have had the privilege of working with chartered architect Jimmy Kim, who has identified various opportunities throughout England to use NHS-owned land or vacant buildings for this sort of development. These sites could be given to the private sector to develop into non-clinical units, with a guarantee of a utilisation contract from the Government. At present, NHS trusts are spending money putting up patients in hotels, with rooms costing as much as £275 per night. One hospital has spent over £1 million on hotel rooms in the last three years. From a cost perspective, it would be better for the NHS to provide this accommodation in symbiosis with the private sector, rather than paying hundreds of pounds a night for hotel rooms or having patients stay longer in hospital beds which are not designed for the context of health rehabilitation.

We need to bear in mind the widening context of what a patient is in today’s society, which is one with dementia, adult-disabled, mental health issues and, progressively, those for whom the social services have yet to find suitable accommodation.

The need to reform both health and care is long overdue. The pressure to invest more in social care has been building up over many years, and Governments have been slow to respond. But part of this must also be looking at prevention and helping people to remain independent, which we can do through supporting rehabilitating patients and helping people to remain independent. We also know that pressure on our hospital system means that many people wait far too long to get treatments, while others stay too long due to there not being suitable accommodation when they are discharged. In too many cases, people end up in hospital for too long or in the social care system where, instead, the step-down accommodation that I am proposing in my amendment would be the most suitable option.

I would love to discuss this further with the Government as I believe that the concept has real merit, as it would reduce NHS costs and improve patient outcomes. My amendment would help the NHS save money and result in better outcomes for patients. I know that one such experiment is being developed now in London; I am really delighted to know about that and I think many patients will be too.

[Baroness Watkins of Tavistock (CB)]

My Lords, delayed transfers in care is an ongoing challenge for health and social care services, made worse with the pandemic. We need to remember that hospitals are for assessment and treatment. As other noble Lords have already said, extensive stay in hospital is not good for your health.

In February 2020, there were over 155,000 delay days in hospital, costing a significant amount of money. A majority of the delays—21%—were caused by delays in packages of care in patients’ own homes, while 18% were due to delays in receiving further non-acute NHS care. With over half a million emergency admissions in the same month, intervention is urgently needed to reduce systematic pressures and maintain safe and timely discharge.

I therefore particularly support Amendment 289 to optimise existing space and develop new accommodation for hospital patients who no longer require acute treatment. There are a range of options, including community hospitals, NHS nursing homes, contracts with not-for-profit social enterprises and, as my noble friend Lady Greengross has said, independent sector companies.

However, these issues are not new. I have in my hands a paper by Sir Cyril Chantler for the King’s Fund, The Potential of Community Hospitals to Change the Delivery of Health Care. The salutary point about this excellent paper is that it was written in 2001.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I rise very briefly, since I attached my name to Amendment 289, in the name of the noble Baroness, Lady Greengross. She set out the reason for the need for this service, but I just want to say explicitly—particularly given the next group of amendments—that I do not believe that independent providers, for-profit providers at least, would be the way of doing this, given the many problems that we have seen in social care, which are highlighted in the next group.

We still have, in some places at least, community hospitals and facilities in communities. These are things that ideally would be developed by the community for the community, being run for public good not private profit.

Health and Care Bill

Baroness Watkins of Tavistock Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 31st January 2022 Lords Chamber

[Lord Davies of Brixton (Lab)]

My Lords, I apologise for the confusion at the beginning of this debate. My understanding of the ways of this House is still a work in progress. I gave notice of my intention to oppose the question that Clause 80 stand part to provide the Government with an opportunity to explain more clearly than they have their intentions for the management of hospital discharge. I hope in so doing they can allay the concerns that surround the proposal to revoke Section 74 of the Care Act 2014. For example, there are the concerns of the National Care Forum, which points to the danger that

“the removal of an assessment prior to discharge will result in less priority to undertake the assessment once someone has left hospital—for someone needing support to remain in their own home, this is concerning.”

The process of hospital discharge is a crucial element within the integrated care system established by this proposed legislation. From the perspective of the service user, this is where it all comes together. It must be done right. The Explanatory Notes tell us that this clause introduces flexibility for local areas to adopt the discharge model that best meets local needs, including an approach known in England as discharge to assess, the argument being that people will be assessed at a point of optimum recovery, allowing a more accurate evaluation of their needs. Who could possibly object?

The first problem is that there is a widespread lack of trust in the Government’s motives and intentions on this, like on other changes in the Bill. It is possible to argue that the change means that people will be assessed where most appropriate. But it is also possible to argue that the change will facilitate premature discharge that is in the interests of the service provider, not the people receiving the service. As well as explaining and stressing the advantages of the proposed change, the Minister needs to tell us what the Government are doing to ensure that it will not lead to the disadvantages that many of those involved in the process fear.

The second issue that the Government need to address is that hospital discharge is still seen predominantly as a medical matter, with concern that insufficient attention is given to the social care aspects. A survey from December 2020 of social workers who were involved in hospital discharges made it clear that the vital contribution of social work in the multidisciplinary team was being marginalised by the medicalisation of people’s journeys out of hospital. Most importantly, social workers were found to feel that the voice of the individual, the person receiving the service, was being lost, indicating that arrangements were being made without consent or against people’s views and wishes.

It is also important to understand the context within which this change is proposed. On the one hand, there is the current crisis in social care. Even without the impact of the Covid pandemic, demand is outstripping supply, there are waiting lists for assessments of need and support, and local authorities are operating with significantly reduced budgets following a decade of austerity. On the other hand, there is the widely understood pressure on the hospital sector, with increased demand and mounting waiting lists. Both these factors are the result of the long-term underfunding of our system of health and social care. This will have to be addressed—just let it not be at the cost of the service user.

We must ensure that community health teams and social care teams have the resources they need to provide a needs assessment as soon as an individual is discharged. Too often, the issue of hospital discharge is discussed in terms of the needs of the service and not of the individual person.

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to speak on this group of amendments, but I want to focus particularly on Amendment 219. There are around 6.5 million unpaid carers in the UK, a number which increased to 13.6 million, or about one-fifth of the population, during the height of the pandemic. Some 1.4 million people provide more than 50 hours of unpaid care per week. Unpaid carers are often relied on to provide this care, yet receive minimal or no formal support themselves. Instead, many report feeling isolated, undervalued and pressured by the challenges of stress and responsibility. Being a carer is emotional and physical labour.

A lot has been said about the Carers UK survey, which identified that 56% of unpaid carers were not involved in decisions about patients’ discharge, with seven out of 10 respondents not being asked whether they were able to cope with having the patient back home and six out of 10 receiving insufficient support to protect their own or the patient’s health and well-being. This lack of support reflects the absence of a unified and systematic approach to identifying and supporting unpaid carers. It demands urgent remediation, especially as we know that unpaid carers are twice as likely as non-carers to have ill health, and the majority have reported worsening mental and physical health during the pandemic.

I endorse Amendment 219 because it talks about carers who work with people who come into contact not just with hospital services but with NHS services. In my work as a community mental health nurse, in many instances I saw that people were not admitted to hospital for years—which was actually a very good outcome—but their carers’ needs were just as great in supporting them with long-term problems in their own homes. This amendment would create a duty in respect of any person receiving NHS care, whether that is in the community or in hospital. The NHS must identify unpaid carers, particularly young carers, and ensure that their health and well-being are properly considered. This is a vital public health duty.

[Baroness Tyler of Enfield (LD)]

My Lords, I strongly support this group of amendments. I particularly endorse Amendment 269 regarding young carers, which was spoken to so compellingly by the noble Lord, Lord Young.

I wish to speak primarily about Amendment 221, to which my name is attached. It is about protecting existing rights of carers. I know that the point has already been made, but it is worth repeating. Amendment 221 would retain existing rights being taken away by this Bill as it repeals the Community Care (Delayed Discharges etc.) Act 2003. I find that a pretty extraordinary position to be in.

I want briefly to focus on the impact of caring particularly on women and employment, without in any way wishing to diminish the very important role played by male carers within the family. It is just a fact that women are more likely than men to be carers. According to some research conducted by Carers UK with the Universities of Sheffield and Birmingham, women have a good chance of becoming carers 11 years before men. Women are also more likely to reduce their working hours in order to care, and they are more likely as a result to have lower incomes and end up under-pensioned in retirement.

As we have heard, hospital discharge can be a pivotal moment for people providing care, particularly women. This amendment would ensure that assumptions are not made about carers’ ability to care, even when they may be working at the same time, that a solution is discussed and, ideally, agreed between families and services, and that carers are provided with the support they need to enable them to care safely and well. For those carers who are juggling work and care, which I can relate to personally, it is essential that their health and well-being are supported. This also has a positive benefit for employers. During the pandemic, the Carers UK research already referred to found an increase of around 2.8 million in the number of people who were juggling work and care, the majority of whom were women. Prior to the pandemic, some 600 carers a day were giving up work to care. During the pandemic, as the noble Baroness, Lady Pitkeathley, reminded us, carers have become the backbone of the care system, protecting the NHS and social care in many cases from collapse.

The Carers UK research also found that 72% of carers providing substantial care and working were worried about continuing to juggle care and work, and 77% of carers said that they felt tired all the time at work because of their caring responsibilities. During the pandemic, 23% of working-age carers providing substantial care had given up work, lost their jobs, lowered working hours or lost income if they were self-employed.

As the NHS works to reduce the backlog of care, hospital discharges will become ever more critical, as will support for carers. The two go hand in hand, and we must not fail those who have so selflessly shouldered such a heavy load.

NHS: Nurse Recruitment

Baroness Watkins of Tavistock Excerpts

Thursday 27th January 2022 Lords Chamber

[Lord Kamall (Con)]

I thank the noble Lord for giving us the opportunity to thank the nurses, and indeed all medical staff, for the incredible work that they do for us, day in, day out. On retaining staff, since 2017 NHS England and NHS Improvement have supported trusts with an intensive retention and support programme. There is also emotional, psychological and practical support for NHS and care staff. It is really important that we not only recruit new staff but retain the great staff that we have.

[Baroness Watkins of Tavistock (CB)]

My Lords, would the Government consider repaying student nurses’ and other healthcare workers’ course fees to retain new, young graduates in the NHS who work, for example, for two or three years?

[Lord Kamall (Con)]

As the noble Baroness will be aware, there is a bursary available to encourage people into nursing but we are looking at completely different training pathways. It is not the old-fashioned way of being trained as you leave school and that being your one chance. We now have a number of different ways in, including degrees and apprenticeships. I could read all the different pathways out but I am happy to write to the noble Baroness with these details.

Health and Care Bill

Baroness Watkins of Tavistock Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 24th January 2022 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to follow the noble Baroness, Lady Hollins, and I completely support what she and the noble Baroness, Lady Verma, have just said. Unless care wages equate with the minimum for personal care in the NHS, we will never resolve this problem. I have been told by the National Care Forum that that means approximately £13.50 an hour. I would like to see that on the record.

The main reason I rise is in support of Amendments 173 and 171, which reflect other amendments looking at the need to ensure that we get workforce planning right for the future. Although we are talking about the future, we are also talking about the immediate crisis in social care.

I was amused at 6.36 pm to get a message from NHS Professionals, which said: “Dear Mary, you are receiving this email because you are registered on our NHS pathway for professionals. We still have many new opportunities that you would be interested in, so please feel free to log in and see now.” I do not know whether the noble Baroness, Lady Chisholm, who is just walking in now, has had the same email from NHS Professionals, but we both logged on at the same time—and she is nodding she has. We will stay here for the time being.

The pandemic has placed a spotlight on the health and care workforce and the pressures it sustained. However, these pressures are against a background of persistent under-recruitment, under-retention and under-representation. This shortfall has serious implications for patient and staff safety, as well as the efficiency of health and care services. In part, as others have said, this has been ameliorated by overseas recruitment. However, as a co-editor of the World Health Organization’s State of the World’s Nursing report last year, I have to say that that is not sustainable or ethical. However, I particularly congratulate the Chief Nursing Officer, Ruth May, for her initiative that enables and encourages refugees to register as nurses in this country, which is clearly an ethical practice.

A strategy to comprehensively monitor and meaningfully respond to the shortfall is essential to support the recovery and development of a strong, safe and sustainable workforce. As it stands, I do not believe that the Bill adequately mandates the actions required to achieve this ambition. As others have said, across the NHS there is a shortage of almost 100,000 full-time equivalent staff, with nursing staff accounting for 40% of vacancies in England. In the last five years, we have seen less than a 10% increase in mental health nursing staff and a continual decline in learning disability services. I understand there is an NHS England ambition for 21,000 new posts across the mental health system. This appetite for expansion—with the view that it translates to a sufficiently staffed and skilled workforce—is welcomed perhaps more so than ever, as 2.8 million people, or 5% of the population, had contact with secondary mental health, learning disability and autism services during 2020 and 2021.

As we are all aware, the workforce shortage is not limited to the NHS. The turnover rate of registered nurses in adult social care is four times higher than in the NHS, with marked regional differences. Getting the right number of staff with the right skills therefore remains a challenge and requires urgent review to maintain quality patient care. In care homes, the shortage of registered nurses has caused some providers to renounce their registration to provide nursing care, forcing some residents to find new homes. In hospitals, high staff turnover and the use of agency staff have contributed to excessive restrictions and blanket approaches to care for people with learning disabilities and autism, for example.

We have also seen an impact on growing waiting lists. In the first quarter of this year, only 61% of children and young people with eating disorders were seen within one week for urgent review—a 72% reduction from last year and falling below the national standard. I therefore welcome the focus on children and young people’s mental health teams, including the proposed approach to facilitate a much better system in schools. However, such healthcare workers will need to be included in workforce reviews to facilitate a system-wide understanding of current and projected needs and resources. We should celebrate that so many people want to become nurses and encourage them to do so by investing not only in university places but in apprenticeship schemes that enable a wide variety of people from different cultural backgrounds to enter the profession.

While workforce data is collected monthly and subject to validation, it is segregated by sector, which makes some comparisons difficult. There are also known data limitations. In social care, only half of the workforce is recorded; in general practice, sessional practice nursing is not directly comparable with the main workforce; and in the independent health sector there is no complete estimate of the total workforce, despite the fact that it provides significant NHS services.

All this necessitates an imperative call for a workforce strategy that goes beyond a five-year snapshot of the NHS. Rather, a collective effort across the health and care labour market, including community nursing and midwifery, is warranted to annually capture and forecast workforce shortages and requirements over time, with a five-year government strategic response and annual update. Without these amendments, England risks a future health and care workforce that lacks the sufficient capacity, competence and diversity that is necessary to achieve more integrated care and safely promote health and support the changing needs of the population.

[The Lord Bishop of London]

My Lords, I will speak briefly on Amendments 170, 171 and 173. As a former Chief Nursing Officer, I recognise the challenge of ensuring the right number with the right skills of those providing healthcare to meet the needs and the future needs of the population. As someone who, while the Government’s Chief Nursing Officer, was given the objective of finding 60,000 nurses, I understand that it requires a whole-systems approach. I often felt it was about science and art—the science was in the work that went on nationally but the art was in the way it was applied locally on the ground. The noble Baroness, Lady Walmsley, talked about how work on the ground is often not about intuition because that is about experience and knowledge; it is about how it is applied on the ground. I also reflect on the fact that although it was my role with all those working around me to find 60,000 nurses some years ago, we are seeking to find almost the same number today. That demonstrates the fact that we do not have a sustainable model of workforce planning and that we need to do better.

We have already heard how the Bill requires the Government to publish a report that describes the systems in place for assessing and meeting the needs of the workforce. We have already heard that that does not go far enough. In meeting workforce needs, systems are required for both planning and supply, but that does not ensure that it will happen. I believe that we need a system that has accountability, that puts into place long-term planning, and that is funded.

The Secretary of State needs to be held accountable for both workforce planning and supply, because there are some things that only the Secretary of State can do. For example, if the workforce planning systems are not co-ordinated at a national level, there is often limited ability to respond to local variations on the ground, such as those between rural and urban settings or between professions or sectors. For example, responding to local variations may require national changes, such as in training or registration.

There are also parts of the workforce planning system for which only the Secretary of State can be accountable. For example, you can assess and put in place workforce plans but unless they are funded, it is done in vain. There are also actions that are often taken at a national level by government, which can impact on workforce supply and which only the Secretary of State can resist. We have seen national policy influence recruitment and retention: for example, as we moved away from the nursing bursary, as we have seen changes in immigration policy and in the challenges faced by the medical profession around its pensions. All those impact on recruitment and retention.

The Health and Care Bill must have embedded in it accountability for workforce planning and supply sitting with the Secretary of State. This will not only ensure good supply but will prevent staff shortages, improve patient safety and the quality of care. If this is not resolved, we will see those deteriorate.

Finally, on sustainability, we have heard how planning for the workforce takes time. We have heard how long it takes to take train a doctor or a consultant or even a clinical nurse specialty. These periods of training reach over the span of a Government. We need a system that does not just respond to the needs of a Government but beyond them, to ensure that our horizons are not limited by politics but by the needs of a population. Our workforce provides not just quality care to an individual but to a community. We have heard how, if we fail to provide the right workforce, we will fail the other aspirations in the Bill.