Care Bill [HL]

Lord Rix Excerpts

Tuesday 4th June 2013 Lords Chamber

[Baroness Wheeler]

My Lords, I shall speak also to Amendment 10. These two amendments seek to make sure that Clause 84 and Schedule 5 specify the responsibility of Health Education England to ensure, throughout its work, the promotion of a comprehensive health service which gives equal consideration to the importance of physical and mental health and the health of people with learning difficulties. This parity of esteem, putting mental health on a par with physical health, must be a key principle carried through HEE’s work and in the education and training of healthcare workers, and it is important that the Bill specifies this. Why is that? It is because the lack of parity continues to have a massive impact. The most recent psychiatric morbidity surveys show that, despite theoretical parity under existing legislation, only a minority of those with a mental disorder in England receive any intervention, in stark contrast to other disease areas, such as cancer, almost all of which have some intervention.

Labour is proud that it introduced the NHS constitution and is pleased that it now has widespread support. However, we acknowledge that it did not go far enough in ensuring that parity of esteem was entrenched into the constitution. This is especially important as the growing number of NHS bodies and organisations established under the Government’s NHS reforms are all required to take the constitution into account in all they do.

Noble Lords will recall that parity of esteem was a hard-fought-for, last-minute inclusion in the Health and Social Care Act. It is vital because it is important to do everything that we can to ensure that this key NHS objective is taken seriously and is underlined at every stage. We welcome the steps in the HEE mandate recognising HEE’s leadership role in this, including a focus on the mental health workforce to ensure that there are sufficient psychiatrists and other clinicians and specialist staff working to build the values and skills to facilitate continuous service improvement, developing training programmes which ensure that all staff have awareness of mental health problems and how they may affect their patients, and ensuring that the mental health needs of people with long-term health conditions are addressed concurrently and not as an afterthought.

We particularly welcome HEE’s leadership role in providing, through LETBs, training programmes to support staff in diagnosing the early symptoms of dementia so that they are aware of the needs of patients, carers and families. Building skills among GPs is especially important in this respect, as we know that patients often go undiagnosed for years. The target for Health Education England of 100,000 staff undertaking dementia foundation-level training by 2014 is a challenging one but it must be achieved if the current appalling level of undiagnosed cases is to be reduced. While focus on dementia is welcome, we must also ensure that other debilitating mental illnesses are addressed with equal vigour.

The lack of parity of esteem for mental health under the current system is widely recognised and acknowledged. The website of the mental health charity, Mind, sums this up well in reporting on the experiences of people with mental health problems. As it says:

“One person told us they get immediate attention for slightly high blood pressure, but face indifference and long waits about their mental health needs unless they are suicidal. Others have told us that they experience far better treatment in A&E for physical symptoms than when they need emergency help in a mental health crisis or for self-harm injuries. This is not acceptable—an emergency is an emergency”.

My noble friend Lord Patel of Bradford reminded us during the debate on the Queen’s Speech that only 13% of NHS funds are devoted to the treatment of mental health issues. Against this backdrop we strongly welcome the Royal College of Psychiatrists’ report, Whole-person Care: From Rhetoric to Reality, commissioned by the Department of Health and the NHS Commissioning Board last year. It sets out how progress on achieving parity of esteem can be made by,

“changes in attitudes, knowledge, professional training, and practice”,

and makes key recommendations to apply across the NHS on equivalent levels of access and waiting times for mental health services, specifically in emergency and crisis mental healthcare.

The RCP report has a number of recommendations relevant to HEE’s remit and role. These include how HEE should as a priority support the development of core skills and competences in health and public health professionals; the need for the General Medical Council and the Nursing and Midwifery Council to review medical and nursing study and training to give greater emphasis to mental health; and integrating mental and physical health within undergraduate medical training. I would welcome the Minister updating the House on what action the Government plan to take on this important report, the timescale for the Government’s response, and how any of the report’s recommendations will be fed into the Bill.

Whole-person care is Labour’s agenda for the future. It would bring together physical health, mental health and social care into a single service to meet all of a person’s health needs. Ed Miliband, in announcing Labour’s commission on whole-person care, emphasised that:

“In the 21st century, the challenge is to organise services around the needs of patients, rather than patients around the needs of services. That means teams of doctors, nurses, social workers and therapists all working together”.

In his landmark speech on mental health last year at the Royal College of Psychiatrists seminar, he acknowledged mental health as the biggest,

“unaddressed challenge of our age”.

He went on to say:

“We have to confront the unspoken discriminations too. Like the vast inequalities in funding for research. Like the lack of training in mental health of many NHS staff – whether in GP surgeries, outpatient clinics or A&E. Eight out of ten primary care professionals say they need more training in mental health than they have”.

Amendment 12 underlines the importance of HEE working,

“with persons who provide health services to ensure an adequate provision of continuing professional development for health care workers”.

That is particularly important in view of the recent findings in a member survey by the Royal College of Nursing, which pointed to a worrying decline in CPD training. The noble Lord, Lord Patel, has an amendment on CPD under the provisions for LETBs, so we will pick up this issue then.

As we progress through the Bill, we will argue strongly for parity of esteem between mental health and physical health to be underlined and specified in the Bill as a guiding principle. When the RCP report on whole-person care was published in March, its president, Professor Sue Bailey, called on government policy-makers, service commissioners and providers and the public to think in terms of the whole person, both body and mind, and to apply a parity test to all their activities and to their attitudes. For Health Education England, this parity test for the planning, education and training of healthcare workers is crucial. Our amendments give force to the HEE mandate provisions on parity of esteem, and we hope they will be accepted by the Government.

[Lord Rix]

My Lords, I support Amendment 10, but I should like to clarify one or two points in the wording. It is possible for a person with a learning disability to have a physical health problem. It is also possible for a person with a learning disability to have a mental health problem. But that is not the main cause or even sometimes the basic cause for their particular condition, which is learning disability. I would therefore have preferred the wording of paragraph (a) of Amendment 10 to have been “learning disability”. The same situation arises in paragraph (b) of Amendment 10. People with a learning disability have a learning difficulty. That is natural. However, there are plenty of people who are not learning disabled who also have a learning difficulty. I would like to have seen Amendment 10 include learning difficulties and learning disabilities, but I actually support the general thrust of the amendment. I hope that if it is accepted the wording of a learning disability can be made quite clear.

[Baroness Wall of New Barnet]

My Lords, I support Amendment 12 in particular. It will be no surprise to the Minister that my interest, even my passion, lies in the status of healthcare workers, which is hugely important. We are recognising that even more by the way in which the continuing change in the health service is coming about.

I wish to pick up on the way the Bill reads in the context of the amendment. The clause refers to, obviously, education and training for healthcare workers. It then refers to,

“the provision of information and advice on careers in the health service”,

but to know where your career is going you have to have a start point. The Minister knows that many of us have been asking for, in the first instance, a recognition of the skills that healthcare workers bring to the job. Across any organisation that has opportunities for development, there is always a start point. A healthcare worker would need to know, for instance, what skills they have and what skills they need to go on to the next stage of whatever career they choose. The ambiguity, at best—actually, it is probably even worse than ambiguity—under which healthcare workers currently operate does not help that process. It will be difficult for the Bill to achieve its objectives if we do not start from the point where healthcare workers have that recognition of their skills in a formal way.

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[Lord Hunt of Kings Heath]

My Lords, we come to a series of clauses that deal with the functions and priorities of HEE. I have a number of amendments in this group. The first is Amendment 11. Clause 84(6) states:

“HEE may, with the consent of the Secretary of State, carry out other activities relating to … education and training for health care workers”.

I am curious to know why the Secretary of State has to give his consent. Does not the mandate in Clause 87 give the Secretary of State enough oversight, without the micromanagement that this part of Clause 84 seems to imply?

Amendment 12A relates to the duty of HEE to ensure that there are sufficient numbers of persons with skills and training. What does “sufficient” mean? Does it mean an equilibrium of supply and demand, or do the Government want an oversupply? This is a matter that the Select Committee looked into, and about which a number of royal colleges are concerned. They take the view that it takes so long for doctors to come through the training grades that one wants an equilibrium rather than a situation where people who have committed themselves to 15 years’ training find that there is no work for them at the end of it. Perhaps the noble Earl might take up that matter with me in writing.

Amendment 14 asks HEE to,

“have regard to any official guidance on staffing numbers and skills mix”.

We will come back to this issue. The Minister will know that the Francis report recommended that NICE essentially should produce benchmarking measures for minimum staff numbers and the required skills mix, including for the number of nurses on wards. It is too late to have a debate on issues to do with nursing staff ratios, but it would be good to know whether the Government will take forward recommendations 22 and 23, because that work will be very relevant to HEE’s own work on the number of staff required in future.

Amendment 19 relates to Clause 86 and deals with quality improvement in education and training. All I ask from the noble Earl is a recognition that in future we will need to revisit the curricula of the universities to make sure that when doctors, nurses and other practitioners leave those universities and are ready to go into employment, they will have some practical-based training from having undertaken clinical duties. I am not convinced that the bodies that set the curriculum have got it right yet. Whenever challenged on these issues, they always claim that everything is hunky-dory and that we should not worry and yet there is a complete loss of public confidence in those training programmes. I do hope that HEE is going to be able to give a kick to those bodies that are concerned with the curricula and those education institutions to ensure that people are ready to practise when they are given their ticket to go into the health service.

On Clause 87, which concerns the objectives, priorities and outcomes of the HEE, I have another series of amendments. I want to tease out the Government’s recognition that, although in the construct of the Bill HEE will have an annual plan, it will also be required to look three years ahead. I wonder whether that is long enough. The argument that has been put to me by a number of organisations is that the time between the commissioning of a training place and that person practising in the health service can be many years. One of the questions is whether it would be better if HEE had to develop five and 10-year plans and match those with the demographic and the demand pressures on the health service. It would be helpful if the noble Earl would recognise the need for much longer term planning.

Clause 88 sets out important matters to which HEE has to have regard. In Amendment 28 I ask whether HEE will have to have regard to a need for equality of funding across England and consistency in education and training opportunities. Given the mismatch between a population and the education and training facilities available, will HEE have a duty to balance where those resources go?

On Amendment 29, will the noble Earl confirm that specialist training-place issues will be dealt with nationally? I need hardly remind him of the sensitivity of this in relation to junior doctor training. I wonder whether it is good enough to leave it to local LETBs to decide. I do think that some national provision and direction is required.

Amendment 30 concerns HEE’s relationship with other countries of the UK. There is a reference to the need for HEE to undertake duties in relation to the devolved Administrations. Surely much more is required. We are talking about a UK health service. Scotland definitely trains more people than is required for the Scottish health service. The same may be the case in Wales which has big problems in attracting junior doctors. There needs to be a UK-wide view of education and training and I hope that the HEE has both the remit and the encouragement of Ministers to work across those borders.

Amendment 32A covers the matters to which HEE must have regard. I have put down an amendment to ask HEE to give specific focus to arrangements for end-of-life care. The noble Earl has taken part in a number of debates on the Liverpool care pathway which have served to raise issues not so much about the policy behind the pathway, although I know that a review is being undertaken, but more about the way in which that has been interpreted by some organisations. It suggests that more is required in relation to the training of staff in end-of-life care. I am sure that in Part 1 we will come back to the issue of social care provision for end-of-life care but it would helpful if the noble Earl could reassure me that this one of the matters that HEE may look at. I beg to move.

[Lord Rix]

My Lords, I wish to speak to Amendment 24, which explores the benefits of placing a duty on the Secretary of State to consult on the objectives and priorities of Health Education England. In particular, I wish to explore how the Secretary of State will consult vulnerable people, including people with a learning disability, to ensure that education and training provided by this body will create a workforce that meets this group’s needs. Consulting and listening carefully chimes with the Government’s intentions through their response to the Francis inquiry, which stated:

“We will listen most carefully to those whose voices are weakest and find it hardest to speak for themselves. We will care most carefully for the most vulnerable people—the very old and the very young, people with learning disabilities and people with severe mental illness”.

This is a most welcome commitment, as currently people with a learning disability are not receiving appropriate care. On Tuesday 21 May, the Parliamentary and Health Service Ombudsman published its report into the death of Tina Papalabropoulos. Tina was 23 and had a learning disability. She died on 30 January 2009 at Basildon hospital in Essex. The ombudsman found that the hospital did not give her the treatment she needed or even meet her basic care needs. Unfortunately, this is not an isolated incident, and there is substantial evidence that poor care exists across the health service.

Early this year, the confidential inquiry into the premature deaths of people with learning disabilities in the south-west reported on its study of the deaths of 233 adults and 14 children with a learning disability. It found that 42% of the deaths were premature and that 37% would have been avoidable if good quality healthcare had been provided. On a national level, this equates to over 1,200 adults and children with a learning disability across England whose deaths should have been avoidable with good quality healthcare. This comes as no surprise to many. The Department of Health highlighted the issue back in its Valuing People and Valuing People Now strategies, and the excellent report by Sir Jonathan Michael, Healthcare for All, set out a series of recommendations for improving care for people with a learning disability. It is these people whom the Secretary of State should consult when setting objectives and priorities for this most important of public bodies. Without the input of people with a learning disability and their families, we will fail to change a system and a culture that in many cases provide substandard care for the most vulnerable in our society.

I realise that the Minister will probably reply that in order to publish the objectives and priorities for the forthcoming year of Health Education England, the Secretary of State will have consulted the parties concerned. However, as an actor who, years ago, used to drop his trousers for a living, I nowadays prefer the security of belt and braces, and I hope that the Minister will be able to offer this.

[Baroness Wall of New Barnet]

My Lords, I would like to understand what Amendment 14 is suggesting, and maybe express some reservations. If I have read it wrongly, I apologise. It is important that Health Education England takes official guidance into account, but we have this dilemma in my own trust about what the Francis report is saying. To have a national edict about what staffing levels ought to be, and the ratios and numbers of staff as well as the skills mix, is not really ideal from the point of view of people operating in the health service, particularly in hospitals. Times change throughout the day on hospitals and on wards, and different levels of skills and different grades of staff are required at different times. You would have to have a permutation that was so huge that it would be less than helpful to have a national edict. I would be concerned that we should take notice of official guidance, but nothing more than that.

I support Amendment 27 and the view about longer-term stuff. In particular—I am sure this will come up later in our deliberations on the Bill, and it is very much in line with what we talked about for a long time in our consideration of the Health and Social Care Bill—the change that is happening as we speak, the evolution of moving, quite rightly in my view as the chair of a provider trust, from acute hospitals to other opportunities to deliver care, is hugely important.

I will share an anecdote with your Lordships. In a discussion with a previous director of nursing in my own trust, I asked her, with my vision of where things ought to be in the future, with nurses following the patient out to their home, how many nurses working on our wards are equipped and skilled to follow Margaret Wall or another patient out and say, “OK, she is now going home”. Her view was very frank: not many would be. I think that is hugely important, because different skills are required to work with someone at home and they need to be incorporated with the skills of nursing overall. It is important when looking at five-year plans, never mind 10-year plans, that we consider the education process in the sense of how people are going to deliver in different environments, which we are all working hard to make sure happens.

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It is our intention that the mandate for Health Education England will be reviewed regularly to ensure that the objectives are current and meaningful to the needs of our health and care system. I hope that those, albeit general, remarks will reassure both noble Lords about our commitment to partnership working.

[Lord Rix]

The Minister appeared to say that most of the people being consulted were professional bodies. He did not mention that people with a learning disability and their families and autistic people and their families were also going to be consulted. He mentioned the list of professional bodies but not the parents, carers and the people themselves.

[Earl Howe]

My Lords, I understand the point. In view of the hour, if I may, I will write to both noble Lords to flesh out the remarks that I have made. I hope that I can give them some comfort in that area.

Amendments 25 and 27, tabled by the noble Lord, Lord Hunt, focus on the importance of long-term and national approaches to workforce planning in education and training, as does Amendment 26. We have strengthened the Bill, following feedback in consultation and at pre-legislative scrutiny, in Clauses 87 and 93 to reflect the importance of HEE and the LETBs taking a long-term perspective on workforce planning and education and training. It is the Government’s expectation that all workforce planning, be it national level planning by HEE or local planning by the LETBs, should be based on a well informed, long-term workforce strategy that looks at needs over the next five years, 10 years or beyond. Any workforce strategy to be credible and deliverable has to be developed in partnership with those partners and stakeholders who have a stake in it. The very same principle applies to the development of national workforce priorities and outcomes and the Government are committed to working with everyone involved in education and training to shape the education outcomes framework and the mandate for Health Education England.

Health Education England will be expected to develop a national workforce plan, building on the local plans developed across England by local education and training boards. I hope that the noble Lord will feel reassured by those comments.

I turn now to Amendments 33 and 14, which seek to amend the Bill to require HEE to have regard to any official guidance and standards on staffing numbers and skill mix. HEE must work with commissioners and healthcare providers to ensure that workforce plans focus not only on how many staff are required but the breadth of skills required to deliver safe services. These plans need to be integrated with service and financial planning so that the needs of all patients and local communities can be met. Individual healthcare providers are best placed to determine how many staff they need to employ, the skill mix required across the various teams and how they need to deploy them to support services and so on. It is the responsibility of individual healthcare provider boards to be accountable for staffing levels and the skill mix of staff in their organisations. Where changes are planned to the size and shape of the workforce, including the skill mix, healthcare organisations must provide assurance that the safety and quality of patient care is maintained or improved. The process should include clinical involvement, leadership and sign off. I hope that these comments will be reassuring.

The noble Lord, Lord Hunt, asked me about the definition of “sufficient” and whether we were talking about equilibrium or oversupply. I will write to him on that, but in delivering that duty, HEE will seek to match supply and demand so far as that is practically possible. It will also promote the importance of a flexible workforce that can adapt to changing circumstances.

I will also, if I may, write on the issue of staffing ratios. I would just say here and now that staffing is clearly not just about crude numbers and not just about nurses. It is also about how the staff work and ensuring that the right staff are in place to meet the needs of the patients whom they are looking after. Again, it is local healthcare providers that are in the best place to decide how to configure those staff in the right way and to ensure better outcomes and value for money. It really depends on the skill mix, the clinical practice and local factors. I think we would say that it is right that nurse leaders should have the freedom to agree their own staff profiles. But I shall follow up that point.

Amendment 19 seeks to amend Clause 86(2) to add to Health Education England’s main functions the promotion of the importance of practical based training in the education of clinicians. I wholeheartedly agree that practical experience while training is essential to ensure that clinicians have the necessary skills to deliver high-quality and compassionate care and have the correct values and behaviours to practise in the NHS and public health system. It is the responsibility of the professional regulators to ensure that the right standards are in place for professional education and training. Practical experience is already a requirement of the professional regulators. Nursing students, for example, are required by the Nursing and Midwifery Council to undertake half of their training in a practice setting. The GMC also expects every medical student to gain practical experience of working with patients throughout their degree. We have placed a strong duty to secure continuous improvement in the quality of education and training on Health Education England. HEE is already working with the professional regulators, as I have already mentioned, to ensure that the Bill remains clear and simple. However, we have not specified the integral elements of the training programmes to which this duty applies. I would add, though, that the need for practical experience is one of the key priorities that the Government have set for the Health Education England Special Health Authority in the mandate. Health Education England will work with the LETBs and healthcare providers to deliver high-quality clinical and public health placements that provide students and trainees sufficient time working with patients to gain experience.

On Amendment 29, I can reassure the noble Lord that, where appropriate, Health Education England will take a national lead in the planning and management of education and training activities. The Bill already makes provision for this in Clause 94(2). The HEE Special Health Authority has already taken on responsibility at national level for crucially important arrangements to manage recruitment into foundation and specialty training programmes for junior doctors. Where there are controls on workforce numbers at national level—for example, in medicine or pharmacy—it will work with partners such as the Higher Education Funding Council for England to develop national plans that will deliver the staff needed across England.

Amendment 30 seeks to amend Clause 88 to add a requirement for Health Education England to have regard to the need,

“to co-ordinate its activities with the NHS in Scotland, Wales and Northern Ireland”.

Of course, it is very important that HEE works closely with the other UK nations in developing workforce plans and shaping education and training. It will be important for it to take a UK-wide perspective and, where appropriate, an EU-wide or indeed global perspective in planning for the future and reforming education and training. I refer the Committee to paragraph 17 of Schedule 5, which enables Health Education England to exercise corresponding functions on behalf of the devolved authorities. The special health authority is already working closely with its partners in Scotland, Wales and Northern Ireland, building on previous arrangements.

I sympathise completely with Amendment 28 and I wholeheartedly agree that there should be equality of funding for education and training across England. Moving to a tariff-based system for funding clinical education and training would enable a national approach to the funding of clinical placements and would provide a more level playing field between different providers. It will ensure that providers are reimbursed fairly for the education and training that they deliver and are incentivised to provide high-quality clinical placements to their students and trainees. For consistency of opportunities across the country, Clause 85 places a duty on HEE to ensure that sufficient numbers of health professionals are trained and available to work in the health service throughout England.

I hope that noble Lords will feel reassured by those remarks. Before I close, I will quickly respond to my noble friend Lord Willis, who expressed concern about the mandate containing little on nursing and support workers. There is a clear and strong commitment to supporting the development of the care assistant support workforce. Similarly, there are clear national priorities focusing on development of the nursing and midwifery workforce. Again, if I can elaborate on that in writing, I would be happy to do.