Health and Social Care Bill

Lord MacKenzie of Culkein Excerpts

Tuesday 11th October 2011 Lords Chamber

[Lord MacKenzie of Culkein]

My Lords, I will try to concentrate on some of the issues that are of concern to me about healthcare and the Bill. First, I should make it clear that my interest in healthcare derives from my being, until nine years or so ago, on the register of general nurses. However, despite being too old to be still registered, it is a truism to say that once a nurse, always a nurse.

I have spent most of my working lifetime defending the health service. I am not going to stand here tonight and pretend that all is perfect, when clearly that could not be the case. There is room for improvement and that can and should be made. That means that sometimes reorganisation might be necessary. Structures cannot be preserved in aspic for ever. However, the NHS has rarely had long periods without organisational change. How often have we heard the cry that the National Health Service needs stability rather than this constant cycle of change that brings ever more cost, usually more bureaucracy, lots of redundancy for senior skilled staff and much more unsettlement for employees?

I have seen more reports and reorganisations than I care to remember. I begin with the Salmon report on nursing. I am not going to read the others that I have on my list. The noble Lord, Lord Walton of Detchant, has already dealt with some of them, and he beautifully demolished the 1974 reorganisation of the National Health Service, which, I recall, was accompanied by the dreaded Grey Book. I will resist listing the reorganisations.

We have also had quite a lot of change in the past few years, and some of that has been good. Despite what has been said about productivity in the National Health Service in recent years, I contend, for example, that the ending of two-year waiting lists, the ending of patients lying for hours and sometimes days on trolleys, the cancer targets, the cardiac targets, the stroke targets and the new buildings have led to better patient experience and outcomes. There are now signs that we are starting to go backwards, certainly at least in terms of waiting times.

Like many, I might have been prepared to give the Bill a fairer wind had it not been for the promises before the election that were largely replicated in the coalition agreement to the effect that there were to be no more wasteful top-down reorganisations. It is not a case of a Government coming to power and looking at the books, which is the usual excuse. One might be forgiven for suspecting that this is a deliberate ploy to tell the electorate one thing while planning to do precisely the opposite.

Of course the Secretary of State in the health department should not be micromanaging the National Health Service. As I see it, this Bill will allow Governments to wash their hands and absolve themselves of any responsibility from any inconvenient questions or issues on healthcare and to blame some of the new quangos the Bill will set up. The powerful speech of the noble Lord, Lord Owen, gave a perfect example here. What if there was to be a pandemic? I would hate to be the Secretary of State who tried to say, “It is nothing to do with us—it is a matter for the chairman of a quango”.

It is not unusual for change to be resisted but leadership is about taking the public with one. In the case of this Bill it is also about taking employees and importantly the many professions with one as well. It is all too easy and too convenient to suggest that persons who fail to agree are motivated merely by self-interest. I do not include the noble Earl the Minister in this—I have never heard him say a disparaging word about health staff in all the time I have known him in this House—but some spokespersons for the party opposite should be more careful than to resort to the lazy argument that, for example, the 4,000-plus public health specialists were either politically motivated or too idle to read and understand the round robin before signing it. That is not the way to influence debate and it is not the way to make friends. It is crass and insulting.

I want to deal with one or two aspects of the delivery of hospital care. I had the unenviable experience fairly recently of observing that at pretty close hand. As a result of a catastrophic error during laparoscopic surgery, I spent almost six months in four hospitals rather than the one night which had been anticipated. As a former deliverer of care, I was on the receiving end and a rather fascinated observer. The specialist surgical team who, I guess, saved my life once the original error was recognised were superb, as were the colleagues who carried out the follow-up surgery some three months later. They were pretty special to be able to make any restorative surgery at all.

I felt safe when I was in intensive care and high dependency. The staffing levels were great, the skill mix was right and the medical, nursing and physiotherapy staff could not be faulted. However, as I later moved from ward to ward and hospital to hospital I took rather a different view. I am not going to join the noble Lord, Lord Waddington, in his general criticisms of nursing staff. I know that nursing has moved on and the patient profile is vastly different, and very many skills and interventions are different because of the advances in medicines and surgery. However, some of the skill sets are the same as when I was nursing, particularly the issue of essential care. Somewhere along the line this has been lost and the status of what we used to call basic nursing is, I fear, no longer there. I am not sure whether this is due to nurse education, the nature of the structures in which nursing care is now delivered or whether it is a cultural matter, but it is one of the issues that needs to be addressed and it is not anything to do with overseas nursing staff, which was being suggested by the noble Lord, Lord Waddington.

Overstretch is a particular problem but one of the real problems is skill mix. Far too often the ratio of registered nurse to healthcare support worker is not right. Healthcare assistants are often left to carry out procedures for which they are not properly prepared or mentored. I support what the noble Baroness, Lady Emerton, said about mandated staffing levels and ratios. Ward sisters and charge nurses are understandably and clearly not doing the same job as when I was nursing. There are some really good exceptions but there is not enough evidence, in my view, of clinical leadership. It is right that the ward sister has a wider role than just getting sleeves rolled up on the ward, but there needs to be a better balance. It is not a return to the matron that we need—it is a return to the authority and to the clinical leadership of the sister or charge nurse. Patients deserve competent and compassionate care.

I was out of the country when the chief executive of the Royal College of Nursing said some nurses were not up to the mark, so I missed most of that debate. Like Peter Carter, my job was to defend nurses and nursing and I have no doubt that if I had said the same things I would have been roundly criticised by some of my members, and I suspect that Dr Carter was as well. However, we have to be honest. If we are concerned about the nursing profession and about patients, we have to admit that not all nurses are up to the mark. I am intrigued by the plans of the Heart of England NHS Foundation Trust to trial quite a different mix of university education and hands-on training. I wish that trial well, because it has the possibility to meet some of the issues about which I am concerned.

My old union, the Confederation of Health Service Employees, always argued for a qualified service. Many people would think that that was a bit optimistic and pie in the sky, but we supported Project 2000 and the drive to university education, rather than just nurse training. But we always wanted support workers, whatever their job titles, to be trained and regulated; that was not at the time supported by other nurses’ organisations because there was a fear that we were trying to replicate the enrolled nurse. That was not so, but there is now a widespread recognition that the public will be and must be better protected by regulation. The present training of healthcare assistants is variable in quantity and quality, yet nursing tasks are routinely delegated. I realise that there are many job titles and many different roles carried out by support workers, but there is a solid case for regulation, and it must be mandatory regulation rather than voluntary.

I shall touch on one other area in which I think that the Bill is deficient—in the commissioning for persons with less common conditions. I refer, for example, to patients with neurological conditions such as motor neurone disease. My closest friend lived with, and subsequently died from, motor neurone disease, and I have seen that ghastly condition at close quarters. Most GPs will perhaps see one case in a working lifetime, and most nurses will never see it. I never saw one in practice, although I have nursed other distressing neurological conditions such as Huntingdon’s syndrome. The concern is that CCGs covering a small population and working in isolation are less likely to be able to deliver the service for patients in this category. I am advised that effective commissioning will need a population size of a quarter of a million for many neurological conditions, and much more like half a million for motor neurone disease. In the latter case, for example, a half a million population would have about 30 people suffering from motor neurone disease. How is it planned that people with less common conditions can have access to the healthcare required? Will the CCGs have a duty to work together to commission those groups? How will that be reflected in the Bill and how will the commissioning board enforce commissioning for those services if CCGs fail to work together? Will there be an advisory group for neurological conditions within the commissioning board?

We have a problem already with some of the CCGs. There are going to be no PCTs, as the coalition agreement said, to act as champions for people with residual services or less common conditions. I am told that in one area of the country there are now seven CCGs but presently one PCT. The charity Parkinson's UK has already agreed with one of the CCGs that there is a need for a specialist nurse; so far, so good, but instead of working together the CCG concerned has already told Parkinson’s UK that it is up to it to convince the other CCGs of the need for a specialist nurse. So much for collaboration. I hope that the Minister can tell us that this is not going to be the pattern that many of us fear.

It is difficult for me to wish this Bill a fair wind as it stands; there is going to have to be major change as it proceeds through this place, and I look forward to much of that.