Health and Social Care Bill

Lord Hunt of Kings Heath Excerpts

Monday 19th March 2012 Lords Chamber

The noble Baroness, Lady Emerton, has put so much thought and effort into her amendment, has taken lots of advice and has worked so hard on this issue. We must resolve it. As other noble Lords have said, the code of conduct is a very good step forward, but we have to secure training and ensure that support workers are equipped to do the job and are not put in positions that make them and patients vulnerable.

[Lord Hunt of Kings Heath]

My Lords, the noble Baronesses, Lady Cumberlege and Lady Emerton, and other noble Lords who have spoken have argued pretty persuasively for statutory regulation. I think it is a pity that the noble Baroness, Lady Emerton, did not put her amendment to the vote on Report because there is a great deal of support in this House and outside it for statutory regulation. I do not know whether the Minister will accept this amendment, but if the noble Baroness wishes to put it to the vote, we shall support it.

If we look at the first part of the amendment, as I understand it the Minister gave an assurance on Report that the Council for Healthcare Regulatory Excellence would provide some assurance to voluntary registers. If the council is prepared to undertake the work to provide some assurance for voluntary registers, I cannot see why it could not have done that for statutory regulation. I have yet to hear one argument by that body or anyone else about why there should not be statutory regulation on this.

I note that the assured training programme is to be mandatory. It is all very well to say that it is mandatory to attend a training programme, but I would rather like to hear that someone has passed some kind of examination and achieved a qualification rather than that they merely turned up and got ticked in—although we know about being ticked in in your Lordships’ House.

On proposed new subsection (3) in the amendment, my reading is that this will not cover nursing homes. The noble Baroness, Lady Masham, expressed concern that a nurse may be struck off the register of qualified nurses but turn up at a nursing home the next day. However, my reading of this subsection is that it relates only to the care of NHS patients. Clearly, there are large parts of the care market to which this does not apply, and the most vulnerable part of care is healthcare assistants working in the independent sector without much supervision.

On proposed subsection (4), the disappointment is that the noble Earl said that the Government would agree to review this after, I think, three years. That would take us to 2015. We know that it would take two or three years to establish statutory regulation, so we are talking about five or six years from now, according to this amendment, when we would achieve statutory regulation. I am sure that that is the journey that we are on; I am disappointed that it will take so long to get there.

[Earl Howe]

My Lords, we have already had considerable debate on standards and training for healthcare support workers at both Committee and Report stages and I have set out the Government’s view that compulsory statutory regulation is not the only way to achieve high quality care.

We have made it clear that we recognise the need to drive up standards for support workers and to facilitate employers to appropriately employ, delegate to, and supervise health and social care support workers. We have listened to the concerns raised in this House and we have already taken action in a number of areas. We have recognised the concerns about the need for common standards for all those delivering personal care. I believe the steps we are taking will help increasingly to professionalise this set of workers, and ensure that healthcare support workers strive to achieve the best standards of skills to enable them to do their work more effectively.

We have therefore commissioned Skills for Health and Skills for Care to work together to develop a code of conduct and minimum induction and training standards for those support workers working in support of nurses and for adult social care workers. We fully expect this code to make crystal clear the primacy of patient safety, and how support workers must flag concerns to their supervisors. It would also be relevant both to employees and to employers. These will be developed by September 2012, with a view to enabling them to be adopted as the standards for an assured voluntary register from 2013 onwards. They will, for the first time, set a clear national benchmark around the training and conduct of support workers.

In taking that work forward, we expect Skills for Health and Skills for Care to engage with nursing professionals, including educationalists, and the standards will link to the Nursing and Midwifery Council’s updated guidance on delegation. We have also said that we will ensure that the delivery of training for healthcare assistants who are entitled to be included on a voluntary register is professionally led. Further, we remain committed to exploring the evidence base relating to ratios of qualified to non-qualified staff, and we will look carefully at the evidence from ongoing work by King’s College.

Our proposals stop short of imposing mandatory requirements on employers, as it is our view that assured voluntary registration, underpinned by the Care Quality Commission’s registration requirements, is likely to be adequate to assure standards. However, we recognise that there are concerns that voluntary registration may not be adequate and therefore, once a system of assured voluntary registration has been operational for three years, we will commission a strategic review of the relative benefits of assured voluntary registration, compared with statutory registration.

The noble Lord, Lord MacKenzie, asked me whether employers would be able to require workers to be on registers. The answer is most certainly, yes. There are already precedents where employers require, for example, clinical perfusionists or non-medical public health specialists to be on voluntary registers, so we do not see this as a problem.

Turning specifically to the purpose of the amendment, to require mandatory assured training for all new healthcare support workers by 2013, I view that as a big-bang approach—if I may put it in those terms—and I have considerable anxiety that it carries a real risk of overwhelming the system in terms of allowing time for an assured training programme to be developed and implemented. Furthermore, I need to bring to the House’s attention that the introduction of mandatory training would have a significant cost impact on employers across a short period.

The department commissioned an independent analysis of the costs and benefits of regulating around 250,000 domiciliary care workers in 2009. This work indicated that, with a requirement that all workers would have to achieve an NVQ level 2 over two years, or have made good progress towards doing so, the costs would be in the region of £435 million over 10 years. The costs of registration, which would have been met by workers, were only around £70 million over 10 years, with the remaining £360 million or so primarily relating to the costs of providing training, which would primarily have fallen to employers.

Therefore, there are good reasons why we cannot just commit to introducing mandatory training in the current difficult public spending environment, without a clear evidence base for doing so. However, that is where the review comes in. I can confirm that we will consider whether there is a case for mandating training as part of that review, and an appropriate timetable if it were to be introduced.

Allowing for a three-year period once such voluntary registers have been quality-assured by the Professional Standards Authority for Health and Social Care is important. The size and complexity of the workforce we are discussing has already been recognised in our earlier debates. Therefore, in order to ensure that the review is fair and evidence-based, we need to allow an appropriate time period for the assured registers to operate and three years from Royal Assent may not allow sufficient time, for the reasons that the noble Lord, Lord Hunt, alluded to, given that it may take some time to get to a point where a register is properly established.

The scope of this amendment is only healthcare support workers, and I understand the reasons why the noble Baroness has raised it in such limited terms. However, as the noble Baroness, Lady Howarth of Breckland, recognised in our last debate on this matter, the care workforce is significantly wider than that of healthcare support workers. Our proposals recognise this and include provision for common core training and a common basis for a code of conduct.

I know the noble Baroness would like us to go further. However, the review to which I have already committed will provide us with a clear evidence base for any further measures needed to assure the standards of healthcare support workers and we will then consider the need for further measures in light of that review. In view of the proposed review and the ongoing role of the Professional Standards Authority in monitoring voluntary registers, I do not see the need to go any further in terms of rolling out the programme with pilots or some such, but we are more than willing to maintain a dialogue with noble Lords and the profession on what is clearly an important issue.

I also listened to the noble Baroness’s point about the importance of staffing ratios, particularly with regard to midwives, and I can confirm that we will keep these issues under close consideration.

I hope the noble Baroness will be at least partially reassured—maybe substantially reassured—about the general direction of travel here and of our commitment to strengthening the assurance processes in place for healthcare support workers and that, as a consequence, she will feel able to withdraw her amendment at this point.