Care Bill [HL]

Lord Hunt of Kings Heath Excerpts

Monday 10th June 2013 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

22: Clause 86, page 73, line 15, at end insert—
“( ) HEE has a responsibility to ensure that its duties under this section are also extended to the Local Education and Training Boards.”

[Lord Hunt of Kings Heath]

My Lords, I wish to make sure that the House is aware of my interest as chair of a foundation trust and as a consultant and trainer with Cumberlege Connections. This group concerns the objectives and priorities established for Health Education England in Clause 87 and that of the LETBs as set out in Clauses 90 to 93. My Amendments 22, 52 and Clause 90 stand part really go to the heart of the relationship between HEE and the LETBs. Past experience indicates that unless one has strong leadership at a national level on workforce issues, one can find that decisions are taken locally, without national consequences being thought through. In the past this has led to an unfortunate reduction in training commissions despite national exhortations not to do so. I want to avoid that happening with Health Education England. I appreciate that under Clause 90, LETBs are appointed by HEE and, I suppose, exercise functions on behalf of HEE. However, I would like to see it explicitly stated in the clause that LETBs will come under the firm direction of Health Education England.

I have to acknowledge that I have been taken to task for my amendments by the Foundation Trust Network for undermining local provider autonomy. I stand corrected. I sympathise, and understand that LETBs must have room to breathe and innovate. However, ultimately, the integrity of a national strategy must be maintained. I hope that the noble Earl’s response on this and, on the ability of HEE to amend the training plans of LETBs if they are considered to fall short, will be positive.

I turn to Clause 92 and my Amendment 47 on the co-operation required between LETBs and local providers. The clause ensures that commissioners must require providers to co-operate with the LETB in planning the provision of, and in providing, the education and training for healthcare workers. Who could disagree with the need for NHS trusts, foundation trusts and other providers to be called to co-operate with the LETBs. But why is this being done through the commissioning process?

I have frequently listened to Ministers, when asked to intervene in the NHS, say that it is a matter for commissioners. I do not want to argue the ideology of commissioning and providing, but I wonder whether that is the right approach in this case. If one thinks of the challenges facing clinical commissioning groups, with small staffs and little experience, can it be expected that they can devote time to ensuring that providers co-operate with each other and the LETBs over education and training? Realistically, I suspect they will have very little time indeed. Therefore, as a minimum the HEE should be required to give guidance on how commissioners are to undertake that responsibility. More substantively, why not lay a direct requirement in the Bill on NHS foundation trusts and trusts on the face of the Bill to co-operate with the LETBs? That would be a signal of intent that NHS bodies could not ignore. I hope the noble Earl might be prepared to give that some consideration.

My third and fourth amendments in the group concern the organisations that LETBs must involve in preparing their education and training plan as set out in Clause 93(4). Overall, this clause is welcome, but it could be improved by my Amendment 49, which adds local authorities to the list. I am sure that the noble Earl will argue that this is covered by Clause 93(4)(c), specifying that health and well-being boards must be involved. However, the importance of these plans goes wider than that. I am sure that the local authority in general in the area of the LETB would have much to offer.

Similarly, Amendment 51 seeks to have patients and carers involved. With all the debate about whether professionals trained to work in the health service are really ready to give clinical care—I go back to the debate we had recently about healthcare support workers—surely patients should have a place round the table, where decisions that have a crucial bearing on patient outcomes are made. Very similar amendments and arguments can be made in support of the amendments of my noble friend Lord Turnberg and the noble Lord, Lord Patel, which I support. However, I hope that the noble Earl will be able to come back positively on the need of patients or carers to have a place and be involved when the training plans of the LETB are being considered. I beg to move.

--- Later in debate ---

[Earl Howe]

My Lords, I would rather have a creative tension than a disconnect. If we get this right the tension will be there but it will be mutually reinforcing. You will have accountabilities running in both directions, essentially, from the national to the local and from the local to the national. In the past this has been a notoriously difficult area to get right. We hope and believe that the structure we are putting in place, in which the LETBs are committees of the national body but which have their own autonomy to a certain degree, will ensure that the tension that the noble Lord referred to really is creative, rather than the reverse.

[Lord Hunt of Kings Heath]

My Lords, that was a very useful exchange. I do not disagree with this architecture, in which national leadership comes from HEE but considerable autonomy is given to LETBs. When looking back at the history of the NHS I remain concerned, as does my noble friend, about failure to implement national strategies in relation to the workforce. This is because decisions are being taken locally which do not fit into the national strategy, particularly over training commissions. This afternoon the noble Earl said that HEE has enough powers to intervene if that were to happen. I think the question is whether HEE has enough national leadership and confidence to actually ensure that a national strategy is implemented. Of course, we will have to see.

On membership, I note the noble Earl’s statement about the number of different professional groups that will have to be covered by LETBs, which is why postgraduate deans are not listed on the face of the Bill. I think that my noble friend really was persuasive on this point. Doctors may not be the only profession, but they are a very important profession. I would have thought it quite extraordinary not to have a postgraduate dean among those around the table of the LETB. Equally, I do not think that the patient advisory forum is sufficient at national level. Considering the NHS record over the last few years, one of the areas causing most concern has been whether trained staff are fit for purpose when it comes to clinical areas. To have a representative of a patient or carer around the table at a LETB would have been very important. However, this has been a good debate, and I beg leave to withdraw my amendment.

Amendment 22 withdrawn.

--- Later in debate ---

[Baroness Cumberlege]

My Lords, I support these amendments on mandatory training. I know that the noble Baroness, Lady Emerton, has fought and fought for this. I served with her on the United Kingdom central council for nursing, midwifery and whatever it was. She pioneered the whole idea of improving nurse training, and it was very successful.

To follow on from the noble Baroness, Lady Hollins, it is interesting that we now have two different parts to the arguments. One concerns the benefit to patients and the public, while the other concerns the benefit to the workers themselves, which I thought was a very interesting angle. It was Terry Leahy who said that he built his empire just by ensuring that all who worked for him felt good about themselves, and I thought that that was very interesting.

I am concerned about how the amendments are fashioned because I am not quite sure what we are talking about. Perhaps the noble Baroness or the noble Lord, Lord Patel, will clarify that for me. We talked about healthcare support workers, and I understand that such workers predominantly work in the NHS. However, subsection (2) of the proposed new clause refers to,

“a health or care support worker”.

I am not sure what a care support worker is, as opposed to a healthcare support worker. Does the support worker work, as the noble Baroness, Lady Hollins, said, in people’s homes? Do they work in residential care? Are they covered by this or not?

The noble Baroness made another point, which I was also going to raise and on which I would like some clarification: what about the people who work for others who need care, through direct payments or personal budgets? Will this rule out those volunteers who often come in and sit with someone, who may do some minor tasks and may even do some relatively nursing-style tasks, such as putting in eye drops, which a member of the family would do? I should like to clarify who we are talking about.

[Lord Hunt of Kings Heath]

My Lords, like my noble friend Lord Campbell-Savours, I remain puzzled by the Government’s approach. I am grateful to the noble Baroness, Lady Emerton, for setting out a number of persuasive arguments for why there ought to be mandatory training for health and care support workers. There seems to be a general consensus around the House and no doubt the Minister will agree with it. My reason for supporting the amendment is that mandatory training is clearly very important, but it is inevitable that if you have mandatory training you have regulation; the two run together. Those who are proposing these amendments ought to recognise that there is an inevitability that if you have training then you must have a list of people who are trained; action has to be taken against those people who have been trained but are then found to be unsafe in dealing with vulnerable people; and there has to be a way of removing them from the list of those who have been trained that has been published. If you go down this route, one way or another you are clearly signing up to mandatory regulation, and a jolly good thing too.

Amendment 23A puts forward an eminently sensible suggestion for healthcare support workers to be certified to show that they have been trained in basic standards, with employers to register individuals who hold such certificates. We need to go back to the Francis report. Mr Francis is widely reported to be disappointed with the Government’s response to his report, and it is not hard to see why. His report commented on the absence of minimum standards in training and competence. This is compounded by huge variations in the approach of employers to job specifications, supervision and training requirements. That is why my noble friend Lord Campbell-Savours has come across so many instances of poor-quality healthcare support.

The Prime Minister’s Commission on the Future of Nursing and Midwifery noted that training for support workers was very variable and recommended that they should be better trained. In response, as the noble Earl told us earlier, the Government have commissioned Skills for Health and Skills for Care to work together to develop a code of conduct and minimum induction and training standards. We now know from the mandate issued by the Secretary of State to Health Education England that it is obliged to establish minimum training standards for healthcare assistants by spring 2014. At this point, I ask the noble Earl: how far does that go? Will it be mandatory for all entrants to the role of healthcare assistant to undertake such training? If that is so, will this extend to care assistants? What about existing health and care support workers? Will this training extend to them, or will it apply only to new people coming into the healthcare profession?

Under the proposals, how will employers know if their support workers have undertaken the minimum standard of training? Will a nationally recognised certificate be issued? Will a national list be established, indicating those who have undertaken such training? If there is not a list, does that not leave a big burden on employers seeking to check whether prospective staff have undertaken the minimum training requirement under the mandate? I come back to the point I made at the beginning: if a list is established, would that, in essence, not amount to a register? If there is such a list or register and it becomes clear that a support worker is unsuitable to care for vulnerable people, is there a way in which an organisation or employer could then apply to have such an individual removed from the list of people who have received the minimum level of training?

Having a certificate showing that someone has achieved a minimum level of training will be generally regarded as a certificate of an ability to practise. If there is such a certificate, there must be a way to remove that certificate if people are found to be wanting. In effect, once one begins to lay down minimum standards and to specify mandatory training, will there not be an inevitable step towards regulation? Amendment 23A poses those questions to the noble Earl. I hope that he will answer sympathetically.

[Earl Howe]

My Lords, I first thank the noble Baroness, Lady Emerton, for an interesting set of proposals and I am grateful for her thoughtful introductory remarks. I agree that ensuring the capability of the health and care support workforce is vital to delivering high-quality care to patients and service users across both health and social care settings. The issue is how we achieve this. Key requirements for delivering high-quality care can best be achieved by providers having the right processes in place to ensure they have the right staff with the right skills and the right training to deliver the right care in the right way to patients and service users.

The idea of statutory requirements can seem an attractive means of ensuring patient safety, yet Robert Francis’s report demonstrates amply that this in itself does not prevent poor care. I confess that I was a little surprised by the vehement support of the noble Lord, Lord Hunt, for the idea of statutory regulation because it was an idea that his Government resisted for some time. I suggest that they resisted it for a number of reasons and they came to the conclusion that it is not as self-evident as some like to make out. That is certainly this Government’s position. This is not, as the noble Lord, Lord Campbell-Savours, suggested, a laissez-faire attitude on the part of the Government. As we made clear in Patients First and Foremost, the initial response to the Francis inquiry, the Chief Inspector of Hospitals will ensure that all hospitals act to make sure that all healthcare assistants are properly trained and inducted before they care for people. I suggest that this is an important step forward.