Care Bill [HL]

Earl Howe Excerpts

Tuesday 4th June 2013 Lords Chamber

[Baroness Masham of Ilton]

My Lords, I, too, support having a nurse on the board. It is vital because the nursing workforce is the biggest of all the professions, and training and recruitment is sometimes the problem that has to be faced.

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

My Lords, we begin our Committee proceedings with a series of amendments that take us to the heart of the theme that permeates this Bill. The driving principle of reforming the education and training system is to improve care and outcomes for patients. Excellent health and healthcare require a training system that will deliver a highly skilled workforce, working together with compassion and respect for people.

Noble Lords will remember our debates of last year when, recognising the importance of education and training in the NHS and public health, we inserted into the Health and Social Care Act a clear duty on the Secretary of State to ensure that there is an effective education and training system. This Bill delegates that duty to Health Education England. This means that Health Education England will be clearly accountable to the Secretary of State for ensuring that there is an effective education and training system in place for healthcare workers in England. Health Education England will provide national leadership for workforce planning, the commissioning of education, training and development activity, and the quality assurance of the education and training that is delivered.

The backdrop to all that is the changing face of healthcare provision. The way health services are provided is expected to change significantly over the next few decades, with more care provided in the community and an increased emphasis on public health. This cannot happen unless we equip the workforce with the skills and knowledge to do this. To do it successfully, the local and national infrastructure needs to be in place to plan and commission effectively. That is why the creation of Health Education England and the local education and training boards is so important.

It is vital that the board of Health Education England has the necessary skills and experience to oversee the delivery of its important functions. In recognition of this, the Government have already strengthened the Bill, following pre-legislative scrutiny, to place an explicit requirement, in paragraph 2(1) of Schedule 5, on Health Education England to recruit members with clinical expertise. The specific nature and description of the expertise and specified numbers are to be set out in regulations. That amendment has been well received by stakeholders such as the Royal College of Surgeons. A similar requirement has been placed on local education and training boards to have members with clinical expertise.

The noble Lords, Lord Hunt and Lord Turnberg, have tabled a number of amendments relating to clinical expertise on the board of HEE and the LETBs. I realise that Amendment 1 is a probing amendment. It may be helpful to explain our thinking around the Schedule 5 requirement. This sub-paragraph was added to the Bill following pre-legislative scrutiny to place an explicit requirement on Health Education England to ensure that there is clinical expertise on the Health Education England board. It also responds to responses to the consultation on the Bill, which touched on the importance of Health Education England having access to professional leadership. This will give Parliament and bodies representing the professions the necessary assurance that the Health Education England board has access to the appropriate knowledge and understanding in making decisions that impact on professional education and training. It also provides the basis for a clear duty in the Bill for both the Secretary of State and Health Education England to make appointments of clinical experts, which can be developed subject to regulations. For example, the regulations will specify what we mean by “clinical expertise” and allow greater flexibility to specify any detailed requirements. It will also allow changes to be made to those requirements as Health Education England matures, should circumstances demand it.

Amendments 3 and 4 seek to extend the requirement for members with clinical expertise by expressly requiring Health Education England to include in its board membership a registered nurse and someone with experience in staff groups that are not professionally registered. Similarly, Amendment 2, tabled by the noble Lord, Lord Turnberg, seeks to extend the requirement for members with clinical expertise by expressly requiring Health Education England to include one or more members with expertise in research and one or more members with expertise in medical education and training in the Bill.

It is undoubtedly important for Health Education England to have access to professional expertise, but having said that I need to make clear that the Government do not believe that it is appropriate for the Bill to mandate requirements for certain professions or particular areas of expertise. That is better suited to be set out in secondary legislation, as it may change over time, and Health Education England will need greater flexibility to recruit the expertise it requires and to specify any detailed requirements as circumstances demand.

One of the great strengths of Health Education England over previous arrangements is that it has a remit for all the professions, bringing a strengthened approach to multi-professional education and training. Although medical and nurse training, and an understanding of the importance of research, are extremely important elements of its functions, HEE has a much broader focus. It may be helpful to the Committee to have a sense of how the new organisation intends to do justice to that broad remit.

First, HEE will employ a director of education and quality at board level who is responsible for ensuring a co-ordinated multi-professional approach to education and training. Within the Health Education England special health authority, that post is filled by a doctor, and is supported by a medical director, a director of nursing, and other professional advisers for dentistry, pharmacy, healthcare science and the allied health professions.

Secondly, Health Education England has established professional advisory groups, bringing together employers and national stakeholders, to focus on profession-specific education and training issues covering medicine, dentistry, nursing, pharmacy, healthcare science and the allied health professions. These advisory boards will support HEE and its board in the decisions they make that impact on health professional education and training. It should also be remembered that Health Education England employs many health professionals that support the activities of the LETBs. In these ways it has direct access to a wealth of knowledge and expertise on the planning, commissioning, provision and quality assurance of education and training.

The Government understand the importance of considering the support workforce that is not professionally registered. Health Education England, with the networks of employers working through the LETBs, will provide a wider leadership role in the development of the whole workforce engaged in the delivery of healthcare and public health. This is emphasised in the Government’s mandate for the Health Education England special health authority. In making non-executive appointments to the Health Education England board, the Secretary of State will source the skills and expertise that are required to ensure the Health Education England board can function effectively. The chair and non-executive directors will do likewise in making executive appointments to the board. That approach has worked well for the recruitment of the current HEE special health authority board, which has three members with clinical expertise, including a doctor. I should also mention that two non-executive appointments are still to be completed. In recruiting for those, we are looking for a further clinician with experience of equality and diversity issues, and someone who can bring a strengthened focus on the patient perspective to support the development of education and training.

In the light of what I have said, I hope noble Lords will feel reassured that the Health Education England board is suitably clinically informed, and that they will feel able to withdraw those amendments.

I now turn to Amendment 5. The Bill already requires the consent of the Secretary of State to the appointment of the chief executive of Health Education England. That approach is in line with the appointment of other chief executive officers across the health system and seems proportionate for a body of this size and nature. In addition to approving the appointment of the chief executive, the Secretary of State will appoint the chair and non-executive directors of Health Education England. This approach has worked well for the HEE special health authority, which has a board with a good blend of experience and expertise.

As for the role of Parliament, the Bill makes provision for Health Education England to report to Parliament on an annual basis, with the requirement to publish an annual report setting out its achievements and to publish annual accounts. I am sure the Health Select Committee will rightly continue to take a strong interest in education and training and will have the opportunity to discuss progress with Health Education England whenever necessary. I hope that will reassure the noble Lord on this amendment.

Ensuring that non-departmental public bodies have robust governance and accountability arrangements in place is clearly essential. Schedule 5 to the Bill makes provision for the constitution of Health Education England and deals with the exercise of its functions and its financial and accounting obligations. A number of amendments in this group fall under that broad heading.

Amendment 6, which again I realise is a probing amendment, poses a question about the terms of remuneration of HEE’s employees. In establishing HEE as a non-departmental public body, it is important that it is given the appropriate levels of autonomy and independence to carry out its important education and training functions without day-to-day interference from Ministers or the Department of Health. Yes, it needs to be held accountable for the use of its resources, and the Government are committed to holding it to account in an open and transparent way, but I hope noble Lords would agree that it is important for a body of this nature to have the ability to determine the pay and remuneration rates for the people it recruits and employs, including its executives. That does not mean that it will not be subject to any constraints. I can reassure the Committee that as an arm’s-length body of the Department of Health, HEE will be subject to the rules and controls covering the use of its budget, and to procedures applicable to senior appointments and levels of remuneration. These are the very same rules that apply to other arm’s-length bodies and to all government departments.

The noble Lord, Lord Hunt, asked me whether HEE employees will be engaged on NHS terms and conditions. In fact, HEE employees are currently employed on NHS terms and conditions and there are no plans to change that when HEE becomes an NDPB.

Amendment 7 is another probing amendment. The provision which the noble Lord has questioned is important. It clarifies that Health Education England’s property is not to be regarded as property of, or held on behalf of, the Crown. This is a standard provision that applies to other arm’s-length bodies in the health system. It allows Health Education England to make arrangements for its own property and office needs. It needs to do so to support the staff it employs nationally and across the local education and training boards. It would not be practical for any other body to hold this responsibility. Of course, Health Education England will work with other bodies to look for savings on estates, information technology, human resources and in other areas. It is already doing that as part of the shared services programme which the Department of Health and all its arm’s-length bodies are signed up to.

Part 2 of Schedule 5 imposes a very clear duty on Health Education England to exercise its functions effectively, efficiently and economically. Part 3 of Schedule 5 sets out how the Secretary of State will fund Health Education England and includes restrictions on the use of resources. These are consistent with provisions made for other bodies in the healthcare system such as NHS England.

I make the same point as I did a minute ago—that HEE needs to be held accountable for the use of its resources—but it is right to give it direct responsibility for how it operates and manages its day-to-day business, including the ability to make arrangements for its own property and accommodation. In the light of that, I hope the noble Lord will feel sufficiently reassured to not press his amendment.

--- Later in debate ---

[Baroness Cumberlege]

Perhaps I may comment on what my noble friend has said in reply to the debate. I understand that under secondary legislation he is considering putting a registered nurse on the board. Some assurance on that would be very helpful. In my experience working with clinical commissioning groups, when they were appointed there had to be a nurse on the board, and the last person to be appointed in many cases was the nurse. There was a feeling that it was hard to find a nurse who would make such a contribution. Some very talented young nurses are coming on-stream, but when one talks about a clinical presence on a board, so often, it is interpreted as a medical person on the board. We seek to ensure that a working nurse will be on those boards. If my noble friend can reassure me that he will consider that very carefully when drawing up the regulations, I will be very pleased.

I am so sorry. I should have declared an interest. My interests are on the Lords’ Register.

[Earl Howe]

My Lords, I listened with care to my noble friend, whose experience we respect greatly. I can tell her that Health Education England’s board will need to have access to a cross-section of clinical expertise, as it does at the moment. Nursing representation will of course be very important. I assure her that we will prioritise that issue in developing the supporting regulations on membership. That is probably as far as I can go, but I recognise the force of everything that my noble friend said.

[Baroness Emerton]

On a point of clarification, the Minister used the term multi-professional education in relation to integrated services. We have concentrated on medicine, nursing and clinical expertise. Because we are going to be looking across the boundaries into social care, is Health Education England going to have anything to do with the social care aspect of the training of clinical specialists? We have not mentioned social care, and I wondered whether we should.

[Earl Howe]

My Lords, Health Education England will have responsibility for the NHS workforce, but not for the social care workforce. We will reach a group of amendments that bear closely on the issue of integration, where I am sure that we can explore the relationship that Health Education England will have with those bodies charged with delivering the social care workforce. The noble Baroness is absolutely right: there needs to be co-ordination and joined-up thinking in those areas. If she will allow, we can wait until we reach that group of amendments before debating the issue further.

[Lord Warner]

Let me assure the noble Baroness that I shall be in good voice on the subject of social care on Amendment 13.

It was helpful to hear what the Minister had to say about advisory committees and advisers. I listened carefully. I did not note anything about those advisory committees or an adviser for what I might call the sub-professional group. I am sure that the professions will be extremely well looked after in HEE, but the groups which we often have the most problem recruiting and ensuring are properly trained are those below the professional level. Can the noble Earl say a little more about those unsung heroes working at the sub-professional level and what kind of advisory capacity HEE might have in that area?

[Earl Howe]

It will certainly be open to the board of HEE to establish an advisory committee that specialises in unregulated professions. Although, again, I cannot make a firm commitment about that, the very fact that we are dealing with a workforce of substantial size on which the NHS crucially depends—I am now talking about healthcare support workers—means that it would be very surprising indeed if the board were not to have some form of specialist advisory service to inform its decisions.

[Lord Willis of Knaresborough]

Before we finish debating this group of amendments, will my noble friend reflect on what he has just said about regulation? One of the traps we fell into with the Health and Social Care Bill—I do not think that it was intentional, it just happened—was that so much was promised in regulation that it was not until we started discussing the regulations that we saw what we had not done in the Bill. Perhaps it would be helpful to produce draft regulations as we go along before Report, so that we know what we are including in the regulations.

[Earl Howe]

It may not surprise my noble friend to know that I asked my officials the self-same question, because I anticipated an appetite for draft regulations. I am, unfortunately, not in a position to make that promise, much as I would like to do so, because there may not be the necessary time available for the regulations to be drawn up in draft. However, I will take back the strength of my noble friend’s request and see whether there can be any reconsideration of that point.

[Lord Hunt of Kings Heath]

My Lords, it has been a very good debate, and I am grateful to the noble Earl and other noble Lords for taking part. It is the role of noble Lords always to ask the Government for draft regulations but, alas, I fear that we may not see them. If we cannot, perhaps we could at least get a sense of instructions that might be given on policy direction.

First, let me say that the Government’s reflection on the Joint Committee’s recommendation with regard to clinical expertise, and the change that has been made, is welcome. I listened with care to the noble Earl when he said that the needs of Health Education England and the education and training of staff may change over time, which is why that is best left to regulation. That makes sense, but I cannot believe that there will ever be a time when research and nurse representation will not be important. I ask the noble Earl to give that further consideration.

I will just reflect on the comment of the noble Baroness, Lady Emerton, that this has been a consistent theme of restructurings over the years. The noble Baroness, Lady Cumberlege, and I have lived through many restructurings and they always start with the premise that there will not be a nurse on the board. Then, after argument and sometimes experience, it is discovered that you need to have a nurse. I would have thought that the Francis report, at its heart, focused a lot on nursing experience and leadership. I ask the noble Earl to give this further consideration. It would be a very visible sign that the Government are listening to this point and that they actually set out in primary legislation that a registered nurse should be appointed.

I am glad that the noble Earl picked up the point about non-registered staff and managerial staff. It is not just in the health service. In the further education sector there is a similar problem, with only a limited number of people applying to be college principals. We need to think very hard about what we can do to give greater support and encouragement to bright young people coming through so that they aspire to take on these top jobs. No one should underestimate the pressures that those leaders are under, but we really want good people. I endorse the noble Earl’s reference to clinicians. We need to encourage more clinicians to take on leadership roles.

I was very interested in the contrast between the desires of the noble Earl not to give autonomy to the board to appoint its own chief executive, but to give it autonomy when it came to the salaries of its staff. I ask for some consistency here. If the Secretary of State appoints the chair and the non-executives—which is absolutely right—he or she should then have confidence in their judgment to allow the board to appoint a chief executive.

Finally, on the intervention of the noble Baroness on integration, it might help our future debate if the noble Earl could confirm that Clause 88, on matters to which HEE must have regard and in which subsection (1)(h) refers to,

“the desirability of promoting the integration of health provision with health-related provision and care and support provision”,

answers the point that the noble Baroness raised—that in effect HEE does have to have an understanding of the needs of those providing social care because of the contribution that they can make to integrated services.

[Earl Howe]

I can answer that immediately by saying yes, it does mean that; indeed, it is that particular provision to which I think the amendment of the noble Lord, Lord Warner, is attached.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful. Having said that, I beg leave to withdraw my amendment.