Health and Social Care Bill

Lord Turnberg Excerpts

Monday 14th November 2011 Lords Chamber

[Baroness Pitkeathley]

My Lords, charities have been campaigning about the VAT issue for many years. My charitable interests are declared in the Register of Members’ Interests. Without doubt, the VAT issue is an unfair burden and a major inequality in the charitable sector. Why should it be of concern to us? Let us think of what charities are good at. In addition to the services outlined by noble Lords already, charities are good at spotting gaps and funding innovative solutions. They are good at bridging gaps, especially between health and social care. They are very good at seeing patients or service users in their particular situations and providing services which meet their needs and not some notional need determined by an assessor. Those things are going to be tremendously important in the new NHS going forward.

Noble Lords should think of the contributions to care and health made by helplines, information provision, carer support groups and specialist nurses. They should think of the particularly significant service of incontinence supplies and advice—so vital to people with disabilities and to older people and their carers—provided extensively by charities. It is vital that charities are not only encouraged to continue to participate, but are also supported to do so—and not to be made subject to additional burdens such as those that noble Lords have outlined. The NHS and social care service cannot do without these services and, most importantly, patients, users and carers cannot do without them. Therefore, we must make it as easy as possible to provide for all qualified providers, including charities. I support the amendment.

[Lord Turnberg]

My Lords, I rise to lend my support for this amendment. I speak here as a trustee of the Wolfson Foundation, which has a programme of support for hospices and care homes and over the years has given many millions of pounds, largely for capital projects. VAT is a constant source of unhappiness to the trustees, and, in fact, they have reached the conclusion that they will no longer pay VAT for capital projects. This means, of course, that the hospices and care homes themselves will have to find that money, which is unfortunate. Therefore, I hope that the Minister will take this amendment seriously.

[Lord Warner]

My Lords, I support the amendment and I do so from a background of having been the chairman of the National Council for Voluntary Organisations and a trustee of a number of organisations that have supplied services to the NHS and local government. This is indeed a very long-running sore; it is a source of grievance. It often goes with another grievance—one which is not germane to this debate but which I might as well mention, because it explains why voluntary organisations are sometimes reluctant to provide some services for public authorities. That is a kind of meanness, almost, on the part of many public bodies about meeting the administrative costs—the management costs—of local authorities. If one takes the two together—a meanness about meeting management costs and being treated unfairly on VAT—this is a barrier to entry.

I fully support the points made by the noble Baroness, Lady Finlay. As the Minister knows, I have probably made myself a little unpopular on these Benches through my support for the idea of competition on a level playing field. I have a later amendment which raises the issue of barriers to entry. This is a barrier to entry. It is stopping voluntary organisations participating fully on the basis of a level playing field as a qualified provider. Therefore, in terms of the Government’s own philosophy in the area of competition, they would do well to listen to these arguments and remove this barrier to entry.

--- Later in debate ---

[Lord Turnberg]

My Lords, my name is attached to Amendment 47B, so ably introduced by my noble friend Lord Warner. I simply wish to emphasise some of the points that he has raised and some of those raised by the noble Lord, Lord Kakkar. The amendment is an attempt to fill a conspicuous gap in the Bill in relation to education and training—namely, to introduce at this stage the idea that we have a Health Education England. I recognise of course that we are waiting for further information from the Future Forum and that we should expect further legislation on this in due course, but this is a subject on which we cannot afford to wait. We need something in this Bill, if only to try to settle some of the many uncertainties that are so disabling for many out there. We cannot wait for a second Bill at some uncertain and probably distant time.

The White Paper Liberating the NHS: Developing the Healthcare Workforce is frankly disturbing in some of its recommendations. Putting responsibility for education and training at the local level entirely in the hands of provider networks—so-called local skills networks—is to my mind, and that of many I have spoken to, both dangerous and potentially damaging. Of course we need, and should have, local input in planning for local workforce needs. However, the standards of education and the level of skills and knowledge that patients deserve have to be set on a national scale. It is not helpful to have a healthcare worker trained solely for local needs who is unable to transfer to another part of the country without going through another local training scheme. Training must be transferable. For that we need national curricula, assessments and levels of achievement, so that when a new healthcare worker joins an organisation, the organisation can rely on that training.

At the moment, for medicine at least, the GMC sets the overall standard and the royal colleges and their specialist advisory committees provide all the curricula and set the exams, assessments and qualifications so that employers and patients can rely on the fact that a newly appointed cardiologist or surgeon, for example, has reached a recognised and approved standard on a national scale. However, most of the medical, nursing and other training takes place at the coal face: in the wards or in general practice by trainers who are themselves practitioners. Here, out and about, the postgraduate deans play the pivotal role because they oversee the whole process of training and planning of the workforce for their part of the country. The deans are the glue that makes it all happen. They control, of course, the budgets for the salaries of all the medical trainees. At the moment, they are employed by the strategic health authorities. When those authorities disappear, the current proposal is for them to be taken over by local provider skills networks. I have already suggested that it would be unfortunate if these bodies were purely NHS providers with little input from those with experience of what education and training entails. Providers may know something about what they want out of it at the end, but they are not set up to oversee and provide the education by themselves.

There are two things that must happen if we are to have a reliable system. First, Health Education England must be set up now, as this amendment suggests. This organisation should become a focus for the postgraduate deans and should probably be their employer. Secondly, we must make more use of the expertise in education that lies in the universities across the country. While universities are engaged in nurse education and that of some other healthcare workers, we must be one of the few countries in the world where universities play little or no formal role in postgraduate medical education. Of course, most clinical professors and their staff are engaged in teaching postgraduates, but the universities have no formal roles. It makes quite a bit of sense, therefore, to consider having the universities play a much bigger role in the local skills networks with the NHS providers. The postgraduate deans might indeed be employed by the universities if they are not to go into Health Education England, although I am not suggesting that their budgets go across to the universities—that may be a step too far.

Perhaps I may ask the Minister whether it would be possible for the deans to be seconded to the local university. It might well be a valuable outcome if the deans could then work closely with local NHS/academic partnerships rather than with NHS providers alone. The example of the academic/health service partnerships set up as collaborations between the NHS and universities to encourage research and the transfer of innovation into practice, as initiated at UCL, might be worth following, and I hope that it might find favour with the Minister. A new partnership built on this kind of model, with deans, providers and universities, and advice from the royal colleges and oversight from Health Education England, would, I believe, find a lot of favour. It would not be providers alone, and it would not be universities alone—where we have seen some of the difficulties associated with nurse education—but a balanced combination of the two. I hope that we can see something emerge along those lines. If that is seen to be the general direction of travel now, even if the detail comes later when we have seen the Future Forum’s report, it will settle many of the anxieties that exist.

I understand that there is an intention to set up an interim Health Education England some time next year, but unless it is given the budget for education, some £5 billion a year, and if the money is instead diffused into local skills networks in the meanwhile, I fear that it will be lost for ever. That is why we should have a clear statement in the Bill now about Health Education England and its funding.

The other part of the amendment refers to the need to ensure that the funding for education and training is not eroded in the changeover, and I hope that the Minister can give us some comfort there, too.

I know that there is much more work to be done by the Government, but we should not leave this until some uncertain future. We must have something a little more concrete in this Bill, and I hope that the Minister will be able to help us.

[Baroness Emerton]

My Lords, I have put my name to Amendment 47B. At Second Reading, I referred to why I thought it important that education and training be mentioned in the Bill, even though it was understood that work was already under way. Noble Lords who have spoken have underlined the importance of education and training being mentioned in statute now.

The Health and Social Care Bill proposes a comprehensive health service reliant on an effective workforce that is capable and competent to deliver a service that demonstrates improved patient outcomes. For this to happen, there needs to be an effective partnership between the NHS and universities. The introduction of local commissioning of services will also require local commissioning for education and training places for the agreed workforce plan at both local and national level. There must be multi-professional involvement if professional silos are to be avoided, both in relation to funding and the structures and governance arrangements that underpin the workforce. For too long, silos have been the problem in the funding arrangements for education, training and research.

Developments around the establishment of Health Education England are now being considered, but, as has already been said, progress is slow and is causing anxiety out in the field. The intent to move to an integrated health and social care service calls for these partnership arrangements to be made. There is a need to ensure the right balance of responsibility and accountability between Health Education England and the provider-led networks—employers/professions, the education sector and the whole workforce, plus patient and public representatives, working together. It is vital that this is a proper partnership and representation on the boards of local education and training boards, which can ensure effective multi-professional workforce planning. Representation of universities, medical schools and postgraduate deaneries, in relation to both non-medical and medical education, on the board of the local education training boards will ensure effective co-production of the healthcare workforce.

Universities should not be considered simply providers of education programmes but also co-producers of the workforce through this wider role of research, innovation, releasing social capital, and the globalisation of healthcare, which is integral to the development of advanced clinical care, service redesign and workforce planning. Universities should work in co-operation with the NHS to ensure the delivery of high-quality education and training and then be held to account by Health Education England. Ensuring that universities are a central part of the local education will facilitate effective partnerships, improved quality outcomes and a multi-professional approach.

The intent to move to this is very important and the establishment of budgets, which has already been mentioned, is also crucial. As already stated, silos should be avoided so that an integrated approach can be established to the education and training of the workforce. The challenge for the new education system will be whether it can truly ensure the co-product of a workforce that can deliver the new way that care can be delivered—one that will provide holistic care, especially adapting to the demographic changes, demanding more care in the community for the elderly, frail, vulnerable and for end-of-life care. Budgets will need to reflect the most cost-effective provision of care to enable hospital expenditure to be reduced.

Nursing, midwifery and other allied healthcare professions are committed to evidence-based practice and would warmly welcome the multi-professional involvement in education and training programmes as well as the benefit gained from multi-professional buildings and shared facilities. Not only would this be of benefit for the learning environments but it could be cost-effective in the use of expensive educational facilities, tutorial staffing and equipment. Could the Minister clarify some of these issues in his summing up?