NHS Care of Older People

Liz Kendall Excerpts

Thursday 27th October 2011 Westminster Hall

[Liz Kendall (Leicester West) (Lab)]

It is a pleasure to serve under your chairmanship, Mrs Brooke. I thank the Backbench Business Committee for allowing us to have the debate. In particular, I thank the hon. Member for Stourbridge (Margot James) for securing it. I also want to thank all other hon. Members who have spoken and given passionate, heartfelt and thoughtful contributions.

Hon. Members from all parts of the Chamber have spoken with one voice. It is completely unacceptable for any older person to receive the appalling standard of care that we have read about in the CQC report and in the ombudsman’s report. We have seen that appalling standard of care in our own constituencies. My hon. Friend the Member for Bolton West (Julie Hilling) has seen it in her own family. Although we may not have seen as poor a standard of care as she did, I am sure that many of us have been concerned about the care given to our own families. I would like to consider some potential causes of those poor standards of care, and talk about possible measures to tackle them and to ensure that every service matches the best standards.

It is important to look closely and carefully at this question and to avoid thinking that one issue, one group of staff or one set of problems is to blame. While there are some straightforward, practical steps that could be taken immediately, there will not be one simple quick fix that will solve the whole issue. There are deeper and more complex issues that are far harder to address. I will talk about five areas: staff levels and resources; staff training, which many hon. Members have spoken about; culture and leadership; the regulation of the NHS; and deeper issues that are very difficult to address.

Several hon. Members, particularly at the beginning of the debate, raised the issue of staffing levels and resources. If we talk to individual members of staff or organisations such as the Royal College of Nursing, they say that the issue is of concern. Staff to patient ratios were referred to by the hon. Member for Stourbridge and the hon. Member for St Ives (Andrew George). Peter Carter, who runs the RCN, gave me a stark example. The figures are rough and not perfect, but he said that paediatric and children’s wards have one nurse for every four patients, while in the wards that specialise in care for older people the ratio is around one nurse for every 10 patients. Elderly, dependent patients have different needs from sick young children, but in many ways they are just as challenging, so we need to look at that, particularly because, with an ageing population and some of the problems in social care, more sick elderly patients are ending up in hospitals, many with not only dementia but two or three other health problems. That co-morbidity issue will be important as we see hospitals with big financial challenges, which we will over the next couple of years.

On staff training, we often hear commentators or senior people in the NHS, frequently medics, who question whether moving nursing towards being a degree profession has been an entirely good thing. It is vital to get the right balance between academic and practical elements in nurse training. Degree courses have been around for many years—40, I think. As many hon. Members have said, we see differences between and even within hospitals that are using nurses with the same qualifications, often from the same universities, and some have their problems and some do not. We need to look at the balance, but we should not think that that is the entire cause of the problem. A lot is down to the culture created in wards, which I will say more about in a moment.

Concerns have been expressed by many hon. Members today, the media and NHS staff about health care assistants. Health care assistants in wards provide more and more of the care, some of which is intimate, such as feeding older people or helping those with continence problems, but it is a positive development. As other hon. Members have said, our staff have the right values, and that is partly about the training they get. I think the hon. Member for Stourbridge said that health care assistants do not get any training and are not regulated, but they do, or should, get training from their employer, the trusts. Such training can be patchy, and we need to look at that.

In 2003, I called for the regulation of health care assistants—as many people did, way before me—in a project I did called “The Future Healthcare Worker.” If nurses are to take on some of the more clinical roles, and health care assistants more care, we need to look at that issue. I had hoped for more progress on that under the previous Government. It would be interesting to hear from the Minister the current Government’s views on regulation. There are all sorts of issues around time and cost—for employers and individual staff—but it is something we need to look at.

Culture and leadership are woolly words, but in practice we know when we see good culture and good leadership. My hon. Friend the Member for Wirral South (Alison McGovern) made this point. What is it on the ward that matters above all? Yes, it is about how long it takes to be treated, whether operations are a success or whether medicine is taken on time, but it is also, crucially, about the experience of the patient, whether they and their families feel that they have been given enough information and the time to think about it. When the information is given can be important. We have all been in situations where the doctor has said something quite shocking and we were not prepared for it. What matters is the simple things such as whether the patients are covered up when they go to the toilet and cleaned effectively afterwards.

There are places where the patient’s experience is at the top of the agenda, not only of the individual ward but of the hospital as a whole. Simple and straightforward surveys, developed by organisations such as the Picker Institute, can help individual organisations and services to get that across.

Another thing about culture is a bit more tricky and concerns how we build a team and being open to questioning. In a team, staff should value each other’s different experiences. That might not be the case with some of the old-fashioned hierarchies in a hospital—doctor, nurse, care assistant—where they do not dare question one another. Teams need to value each other’s skills and experiences but also be open to questioning.

[Alison McGovern]

One of the best examples of quality of care that I have seen recently was in one of my local hospitals, when I was shown around a ward in part by the cleaner, because she was deemed to be so important to the good functioning of that ward.

[Liz Kendall]

That is absolutely right. It is not that everyone has the same skills and experience, but that all those different skills and experience are important. In a proper culture of learning, mistakes can be admitted, because we all want to learn from them to ensure that they do not happen again. We need to see not only the different health professionals as part of the team, but users and families too. Peter Carter of the RCN raised the issue of families being involved, and it was sad that all over the papers he was reported as saying, “Come in and care—it is up to you to care for members of your own family.” What we need, though, is for families to be part of the process, particularly if their relatives are elderly patients suffering from dementia. Family members know them best. We might not be able to hear what they are saying but their family will know how they react, and whether they like or dislike something.

Such a culture and such leadership need to be in evidence not only on the ward, but on the board—a point made by the hon. Member for Stourbridge. As the boss, the board should want to know what is happening on the ward and its members should be getting the surveys and patient feedback. As with Members of Parliament, hopefully, what they will most want to know is what individual constituents think of them. Accountability is vital, from the top down. Also, in particular for old people who might not have family members nearby, the idea of volunteers who can be advocates and part of the process is important.

On regulation and the Care Quality Commission, I am concerned about the issue. More could be done immediately. The CQC has an important role to play, but I want to be clear that responsibility for the quality of services lies with the providers and not with the regulator. However, people want to have confidence that, if the CQC says that somewhere is okay, it is okay and, if it is not okay, that the CQC will go back and ensure that it is sorted out. I am concerned that, almost six months after the initial inspections, the CQC has not been back to a third of the hospitals it said in its report were failing to respect and involve older people, and it has not been back to two thirds of the hospitals that were failing to meet nutritional needs. I have written to the CQC, which has not written back, but it said on the phone that it had received written reassurances. That is not good enough. It should be going back to those hospitals. I am keen to hear from the Minister whether he could take action to ensure that we know which hospitals have not had a follow-up and what the timetable for action is.

There are clear national guidelines for people who work for public bodies such as the council or the NHS. There are guidelines on raising the alert and referring a person immediately—within one day—if it is thought that they are vulnerable or at risk of neglect or abuse. I have asked the CQC whether it referred people, or whether it required the hospitals to do that. If someone has seen children at risk of neglect or abuse, action would need to be taken or they could face the legal consequences. I am concerned about that matter.

I have spoken longer than I intended. I want to finish by addressing what I call “deeper issues”: our model of health care, the nature of medicine and the way we as a society treat older people. When our NHS was established, our population had very different health problems. People needed episodes of care for acute conditions that could be treated and increasingly cured. Our health services were based on the model of individual district general hospitals. However, we have health problems now that are related to people living longer with long-term and chronic conditions. Improving health is no longer solely about needing episodes of acute care that seek to cure people. It is about increasingly helping people to manage their long-term health problem, and, when they are very old or suffering from dementia, helping them to live to the end of their days as comfortably as possible.

Our model of health care has not kept pace with changing needs. One third of hospital admissions are for people over 65, but, because on average they stay in hospital twice as long, two thirds of hospital beds have an older person in them. Hospitals are not the place to care for older people, but hospitals are where we care for them. We must change that situation, which means shifting services out of hospitals and into the community. We need to focus more on prevention and joining up with social care.

There is a big challenge for medicine. We have talked a lot about nurses, but not about doctors’ mentality. They are trained to cure. There is a big challenge for doctors as well as nurses as our health needs change. In too many places, doctors are still at the top of the hierarchy. They are the ones who help to determine the shape of care. It is important to look at their changing role, too.

I want to talk about how we as a society treat older people. I hope we will have a proper debate about that one day. I want to say two things. First—I think other hon. Members have mentioned this—we are not used to seeing people get so old. It is quite a recent thing to see people living for such a long time, often in pain, and it is very painful for families, particularly if they see people whom they love suffering with dementia. Society shuts older people away too often. We say, “You’re just getting old” or we prefer that they are not seen and not heard. In other countries, it is not like that. Older people feel more part of the community and they are perhaps more visible than in this country. I can give a simple example. Care homes in Spain do not have opening hours—they are simply open—and people see them as part of the community.

The issue is about how our services cope with an ageing population and how we treat older people. If someone is very old and slowly dying, including from something such as dementia, which is awful to see, we need to find a new way to deal with that.