NHS: Staff

Lord MacKenzie of Culkein Excerpts

Thursday 30th November 2017 Lords Chamber

[Lord MacKenzie of Culkein (Lab)]

My Lords, I too am delighted that my noble friend Lord Clark of Windermere has secured this very timely debate. I agree with every single word, I think, that he said. Given my own nursing background, I will perhaps single out from among the other speakers the powerful speech by the noble Baroness, Lady Emerton. She touched on a lot of extremely important matters, and the news that she may shortly be retiring from this place will leave the House much worse off when it comes to dealing with very important health matters, particularly nursing.

There are lots of warm words about nursing and lots of compliments for the work of nurses, midwives and health visitors, and this is something that Ministers are only too happy to join in with. We had it from the Chancellor in his Budget speech in the last few days, when he said:

“Our nation’s nurses provide invaluable support to us all in our time of greatest need and deserve our deepest gratitude for their tireless efforts”.—[Official Report, Commons, 22/11/17; col. 1054.]


Nobody could argue with these words, but nurses and other health staff were expecting something more when it came to the rest of the Budget speech. The scrapping of the pay cap was announced, I think, last October. The widely expected nod in the Budget to a decent, unconditional, fully funded pay rise did not materialise. Instead, any increase above a miserable l% seems to be conditional on changes to the Agenda for Change pay structure.

I agree that there may be some aspects of that structure that might need to be looked at, tweaked or updated, but the real suspicion is of course that the Government want to reduce or remove payments for unsocial hours, and that they may want to deal with issues about so-called automatic increments and put new bars to progression on the incremental scales. We have already heard about issues of productivity, and I agree with the noble Lord, Lord Warner, that any negotiations with the staff unions that propose taking some of these conditions of service away are going to be extremely difficult.

I also do not know, and would like to know from the Minister, what is meant by productivity. How do you measure a nurse sitting down and talking with a patient? Are they supposed to be on the move every minute of every hour? Nurses, midwives, health visitors and most other health staff are working at full pitch, and I do not really know what is meant by productivity increases. I hope that the Government and the Secretary of State are not setting up the staff side for blame if they fail to reach agreement on some of these proposed robbing Peter to pay Pauline suggestions that may be coming forward. I can hear it now: “You would have got a bigger increase, but the wicked staff side failed to reach agreement with us”.

I have been around the health service and health service trade unionism for all of my working life until I came into this place. There have been many ups and downs and issues in nursing morale over the years. We have had good times, better times and a lot of bad times, but I am not alone in saying that it is worse now than I can ever recall. Pay and grading is of course one of the issues that affect nurse morale—how could it not be when pay is something like 14% lower in real terms than it was in 2010? It is an important reason why nurses leave the profession. Nurses cannot pay their bills, and in some cases need to go to food banks.

However, as soon as we ask a Parliamentary Question about nursing shortages, pressures or pay, what do we get? With the greatest of respect to the Minister, what we get are the formulaic, boiler-plate Answers telling us that we have X more nurses than we had in 2010 and have created Y more training places, and that pay is for the independent NHS Pay Review Body. The review body used to work reasonably well and held the ring between the Government—the Department of Health—and the staff side fairly well before it was effectively captured by the Government’s freeze and then the 1% pay cap.

We need to unpack these ministerial Answers. There may be more nurses now than there were in 2010, but that takes no account of the growing demographic change in the population. There are more elderly people than ever before, and that means more co-morbidities. There have been huge advances in medicine and surgery. We have fewer acute beds in this country than most OECD countries. For example, Germany has over six per 1,000 population, while we have less than 2.5. Perhaps that is why ambulances are queuing for far too long outside A&E departments, patients are not seen within target times, patients are on trolleys in corridors and, as we have heard in this debate, patients are sometimes discharged inappropriately early or in the middle of the night, without adequate provision at home, so that room can be made for the more acutely ill patients waiting in A&E.

It is not therefore surprising that there are huge pressures on nurses and other staff when on duty. There are 40,000 vacancies for nursing staff in England alone, and that takes no account of increasing shortfalls in the other UK countries. It is therefore not surprising that some research tells us we have the highest nursing workload and consequent burnout in Europe. That does nothing for staff morale either.

Then there is the hopeless funding of social care. How much did we hear about social care in the Budget? “Hopeless” seems to me to be the operative word because, without significant investment in social care, the future looks grim. That in turn adds to the pressures on the health service.

Ministers are fond of referencing 2010. In 2010, we had over 8,000 nurses working in social care, but there are fewer than half that number today, while nursing homes are having to close or reregister as care homes. The continuing lack of investment in social care is going to put even more pressure on the hard-pressed NHS, despite the additional funding that, while welcome, will be nowhere near enough to avoid the continuing pressures and problems. Some 40% of the funding needed is all that was offered—better than nothing but not good enough, as the funding asked for by Simon Stevens would only have returned us to the level of increases that we had in the first 60 or so years of the NHS.

A more recent but very important matter affecting the retention of nursing staff is the dramatic reduction in the funding for continuing professional development. We have already heard the figures: the budget, which was £205 million, has been chopped down to £83 million. Part of continuing professional development is the requirement that all nurses revalidate their registration every three years, but by far the largest part of the funding is needed to develop nurses and nursing as well as to bring in new roles. Why put the brakes on preceptorship for newly qualified nurses as well as the career development that is so important? Employers cannot now develop programmes for A&E, for operating theatres, for district nursing or for advanced practice in anything like the numbers that are needed because of the huge disinvestment in CPD. I understand that the Government did not reduce CPD for doctors, so why did they do it for nurses? Can the Minister explain the disparity between the ways in which the two professions have been treated? These are but some of the reasons why members of the nursing profession are unhappy.

I turn to the matter of joining the profession in the first place, where again we have had a huge disinvestment, this time by replacing the bursary scheme with student loans. We have heard much about how this plan is going to increase the number of university places available by not having a capped commissioning system; we are told that it would give students much more money. We heard some of that from the noble Lord on the Front Bench yesterday. Universities were up for it, at least initially, because they are in a marketplace and the prospect of more students brings in more money. Perhaps the most important reason is the fact that the Treasury hopes that, by introducing the wheeze of ending bursaries, it will save £1.2 billion. Is that fact or fiction? After all, I cannot see where that £1.2 billion has been reinvested in the NHS.

It may be that many nurses will not pay back their loans because, if they stay in the nursing profession in the health service for 30 years, they are unlikely to earn enough to do so, but what of the effect on the potential recruits? It is a long time since I started nursing, but in Scotland we could start nursing at 17 and a half. I recall that two or three out of that first year could possibly have been referred to as mature students; the rest of us were all youngsters. Similarly, in my post-registration training south of the border, we had a nursing cadet scheme where most people came in at 16 as cadets and commenced nurse training at 18. Mature students were almost unknown. It is a totally different situation today. Many students are mature or have family responsibilities. I cannot see how they would want to come into the profession now, with the risk of being saddled with a student loan for many years to come. It is a perception thing, and it is extremely important that the Government keep the matter under review and carefully monitor it.

There is one bit of good news that I would like to touch on, and that is the development of the new nursing associate. The measure is long overdue and, provided that it is developed correctly, it will give an opportunity for many who do not want to do the full degree course to become a registered nurse. That is something that my old union, the Confederation of Health Service Employees, campaigned for at the time of the ending of enrolled nurse training, but it did not happen. Still, what goes around comes around.

My concern here is that we do not return to the situation that we had with enrolled nurses and that the substitution of the nursing associate for the registered nurse becomes a fashionable thing, particularly with pressures on finance. The awfulness of what happened in Mid Staffs is not so long ago that it can be erased from health boards’ corporate memory. We know that the fewer the registered nurses, the greater the mortality risk. I do not want to see any substitution here of registered nurses by nursing associates.

I just wish we could stop this nonsense of nursing associates already being referred to as “associate nurses”. It is important that they are going to be registered by the Nursing and Midwifery Council, but a nursing associate is not a nurse. I wish we could regulate and protect the word “nurse”. The phrase “registered nurse” is protected, but the word “nurse” is not. We have health trusts applying the label “advanced nurses” to people who have never seen a bit of nurse training in their lives. That should not happen, and it is something I would like to see the Government getting a grip of.

My time is up, but there are many issues that have to be addressed if we are to resolve some of the issues that have been raised in today’s debate. I forget who it was who said it, but if these things are not dealt with then rivulets of discontent could reach flood proportions. I hope not—we have been there in the past and I do not want to see it in the future. There is much work to be done, and I hope the Government can get a grip on some of these difficult issues that we face.

NHS: Wound Care

Lord MacKenzie of Culkein Excerpts

Wednesday 22nd November 2017 Lords Chamber

[Lord MacKenzie of Culkein (Lab)]

My Lords, I am delighted that my noble friend Lord Hunt of Kings Heath was able to secure this important short debate, which was so ably introduced by my noble friend Lady Wheeler. As a former nurse, I find this subject of obvious interest. As someone who was at the receiving end of suboptimal wound care some nine years ago, and has residual problems to remind me every day, I find that interest reinforced.

Wound care is no longer part of what many years ago used to be called basic nursing practice. Obviously, I expect that all registered nurses will know a lot about wound care—but nowadays it is much more than that. Before treatment there have to be proper diagnosis and proper identification—or perhaps I should say classification—of the wounds. There are many types of wounds: surgical incisions; abrasions; granulating or overgranulating wounds; and diabetic foot ulcers and ischaemic leg ulcer wounds, about which we have already heard quite a bit in the debate.

One of the least excusable wounds to me, as a nurse, is the hospital-acquired or care home-acquired pressure sore. It should never be forgotten that sloppy, incorrect care of a tiny wound, as in a jugular vein cannulation site, can lead to sepsis, with all the horrors that follow, such as acute kidney injury. I know because it happened to a relative of mine very recently.

There is no doubt that the care of wounds is staff-intensive, extremely costly to the National Health Service and, not least, costly to the patient in terms of pain, infection and immobility. Wounds not healed within, say, six weeks can be defined as chronic. There are many factors which delay and impair wound healing, including: underlying disease; reduced blood supply; infection; malnutrition; poor patient compliance; and, indeed, smoking and alcohol. There are more, but I am not going to list them—except to say that one of the most important is inappropriate or poor wound management.

It is here that I will speak about the role of the tissue viability nurse. That nurse specialist comes into their own in cases of wound management. They have an important role in clinical practice. Their skills are important so that there is correct diagnosis and classification, which in turn will lead, one hopes, to the correct treatment—there are huge variations in the types of tissue damage in different wounds. Is the wound clean? Is there debris? Is there infection? Is there pus, a lot of exudate or a lot of necrotic tissue? All these issues have to be identified before treatment.

The tissue viability nurse also has an important role in prevention; in education; in research; in working with other National Health Service teams, including pharmacists, and, ideally, outside the hospital with, for example, community staff, care homes and hospices. It is, or should be, part of the tissue viability nurse’s role to educate senior finance and procurement staff about what really works in wound care. Tissue viability nurses, individually or in teams, have the capacity to reduce trauma for patients and mitigate the huge costs to the health service, but there are too few of them, too few specialist doctors and far too many protocols. As my noble friend Lady Wheeler said, there is a vital need for a nationally agreed and properly resourced strategy to improve prevention and, where prevention fails, to improve the quality of wound care and thus reduce costs.

I turn to dressings. There appears to be increasing pressure to redefine what we used to call “cost-effective treatment” in relation to wound dressings to mean the cheapest—or, in the jargon currently used in procurement, those said to be “clinically acceptable”. That is not necessarily the best way to reduce costs. Dressings classified as “acceptable” cannot always be those that are clinically indicated and appropriate. If healing is compromised and delayed, that which might be acceptable to accountants becomes, in fact, the antithesis of what is really cost effective. Doctors, tissue viability nurses and other nursing staff need to be able to access the treatment which is essential to promote the best outcome —for the sake of the patient and of the service.

I have no problem with cheaper generics when it comes to paracetamol or the many other drugs which have exactly the same formula as the more expensive branded versions. This is not so in the highly specialised field of wound dressings and treatment. Cost must not be the primary driver.

My daughter, who is involved in clinical teaching, tells me that programmes that have been developed to carry forward professional development in her trust are now severely curtailed by the massive reduction in the funding for continuing professional development. That includes development of courses on issues such as wound care.

We are seeing reductions in opportunities for training, the drive for the cheapest possible procurement, the huge workload pressures on nursing staff in hospitals and, even worse, in the community, as evidenced by the massive reduction in the numbers of district nurses. All those factors together must militate against the good developments in wound care. There cannot be any argument against the need for a coherent national strategy if we are to reduce poor outcomes for patients and reduce the costs involved.

I hope that this short debate will reinforce the seriousness of this matter to the Government and give the Minister the opportunity to tell the House what plans there are to increase, for example, the number of tissue viability nurses so that there can be more support, not just for staff in hospitals but for hard-pressed community staff and for nursing and care homes. Will the Minister say how the important matter of wound care is to be taken forward? Will there be a new coherent national strategy? I very much look forward to his response.