Care Bill [HL]

Lord Hunt of Kings Heath Excerpts

Tuesday 4th June 2013 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

1: Schedule 5, page 104, line 28, leave out sub-paragraph (1)

[Lord Hunt of Kings Heath]

My Lords, it is a great pleasure to open the Committee stage debates on the Care Bill. Schedule 5 relates to the establishment of Health Education England as a non-departmental public body. Schedule 5 is concerned with the membership of Health Education England and other matters to do with its establishment. As this is the start of Committee stage, I declare an interest as chair of an NHS foundation trust, and as a consultant and trainer with Cumberlege Connections.

The education and training of staff in the National Health Service is of course a critical responsibility, on which patients depend for good outcomes of care. The UK has traditionally enjoyed a very high reputation for the quality of our training and educational institutions and for the standing of the professional staff who come into the National Health Service. However, we should also acknowledge that there are a number of challenges facing the UK in ensuring that we continue to produce the right kind of people, in the right specialties and in the right numbers, taking into account the long-term challenges we face, not least that of an ageing population.

We received lots of briefings for this part of the Bill, for which I am most grateful. I was particularly struck by the briefing I received from the Royal College of Physicians, which points to trends in medical education and training. On demography, it points out that by 2033 there will be 3.2 million people above the age of 85, with the prevalence of dementia expected to double. On social trends, people have more choice and higher expectations. On efficiency, the economy of course will shape services substantially and we know that, in the short term at least, the NHS faces unprecedented austerity.

While the Royal College of Physicians believes that many elements of the current training structure are excellent, there is a need for change too. Many more physicians must train in internal medicine to meet the new needs of patients across hospitals and community services. There is an emerging view that too many consultants specialise too soon and that there is a need to focus more on general physician consultants if we are to meet some of the problems that hospitals are facing. A&E is a symptom of the need for hospitals, in particular, to change the way they are often organised in order to recognise that their key client group are frail, older people who probably need the attention of generalist physicians as much as speciality doctors. The RCP points out that the doctor-patient relationship is evolving and that this needs to be reflected during training. It says that there should be more flexibility for time out of training and career progression between different grades which meets the changing needs of the health service.

Every royal college and many trade unions and patient groups have made similar comments about the need to look at the training and education of our professionals. We know that there are formidable challenges with regard to nurse education. The Francis inquiry identified a number of these. There is a real worry that newly-qualified nurses are not well prepared to take on full nursing responsibilities. The excellent independent report of the noble Lord, Lord Willis, commissioned by the RCN, contains some very important messages for us in our debates. There is a debate among the public and in Parliament about whether the caring aspect of nursing has sometimes been neglected. There is also the issue of whether healthcare support workers lack mandatory training and registration. I have no doubt that we will also debate those matters.

The connection between this and Schedule 5 is that Health Education England will be faced with many interesting and difficult issues. I can say to the noble Earl that we support the establishment of HEE in statute and I am very glad that Sir Keith Pearson has been appointed as chair of that organisation. The noble Earl will know that he was previously the distinguished chair of the NHS Confederation and an NHS trust. He brings to the job a wealth of experience.

The amendments in this group are designed to enhance the ability of Health Education England to understand the pressures that the service is under in relation to staffing and to ensure that our education and training is flexible to the rapidly changing face of health and social care. There are three amendments concerning the membership of Health Education England, as set out in paragraph 2(1) of Schedule 5, which states:

“The members of HEE must include persons who have clinical expertise of a description specified in regulations”.

Amendment 1 seeks to delete that but I hasten to add that it is a probing amendment. I have no problem at all with people of clinical expertise being on the board—far from it. However, I seek assurance from the noble Earl that one of the members appointed will be a registered nurse. This relates also to Amendment 3.

I need hardly speak to the House of the importance of nursing issues to the workforce and to the work of Health Education England. I remind the noble Earl of recommendation 204 of the Francis report into Mid Staffs. It states that all NHS bodies,

“should be required to have at least one executive director who is a registered nurse, and should be encouraged to consider recruiting nurses as non-executive directors”.

I hope that the noble Earl will be able to respond positively. The nursing workforce is so important to the quality of care that it is crucial that Health Education England has nurses around the board table both on the executive and non-executive sides. Every time there is a restructuring of NHS boards, often there will be people who try to exclude nurses from those boards. They are mistaken. I do not think that boards in the NHS can do without nurses around the top table.

My noble friend Lord Turnberg will of course speak to his own amendment but I support its thrust, which is to appoint one or more members with expertise in research and one or more with expertise in medical education and training.

I also hope that recognition will be given to the needs of those staff who are not professionally registered. My Amendment 4 refers to that point. How are the needs of healthcare assistants going to be met if there are not people around HEE who understand the constraints and pressures under which they work?

Managers in the health service, many of whom are not qualified in the traditional sense of being professionally registered, have a crucial role to play. I had hoped that Health Education England would be concerned about the identification and development of those managers. I remind the noble Earl that there is a big problem in recruiting chief executives to NHS bodies, perhaps because their length of stay is almost as bad as that of football managers. That tells it own tale about the job. I hope that Health Education England will consider that it has some responsibility to look at how the managerial cadre can be developed and trained, and how they can be given some security in their jobs and reassurance about what will happen to them if they need to move on from one organisation to another.

--- Later in debate ---

[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.

Amendment 1 withdrawn.