Health and Social Care Bill

Lord Turnberg Excerpts

Tuesday 13th March 2012 Lords Chamber

[Baroness Masham of Ilton]

My Lords, we are once more discussing the important matter of the power to regulate healthcare support workers in England. I am pleased to have added my name to the amendment. I spoke about this at Second Reading and in Committee. I agree with the Royal College of Nursing that mandatory regulation and registration of these support workers is important in order to safeguard patients’ safety and to ensure standardised training so that there is a skilled and suitable workforce.

I have yet to meet anyone who understands the situation who disagrees about this, except some members of the Government. Nurses who have been struck off their register can then work as care assistants—again, putting patients at risk. The Government are considering a voluntary register, but this will not cover the undesirable people who get jobs as care assistants because they cannot get employment elsewhere. Clinical physiologists have found that self-regulation, which they have had since 2001, is not as effective as statutory regulation. Should we not learn from this?

We know of the tragic cases at the Mid Staffordshire NHS Foundation Trust, where the deaths of hundreds of patients were associated with bad care. It makes one wonder how Mid Staffs was approved for foundation status. We also know of the horrific bullying by care assistants at Winterbourne View care home at Bristol. Since Committee, we have heard of Malcolm Cramp, who was convicted of seven counts of ill treatment and sent to prison for abusing dementia patients at Brockshill Woodlands, a care home in Leicestershire. In another case, Sean Abbott, a caseworker, was jailed for a year for assaulting vulnerable residents at St Michael’s View care home in South Shields. Daphne Joseph, another person at that home, was given a nine-month suspended sentence when she admitted the ill treatment and neglect of a patient, who died. The judge at Newcastle said that she had not had enough training. He also said that she was operating,

“in a regime which was inadequate and not fit for purpose and in which there were too many patients, not enough planning, and too few staff, let alone trained staff”.

This concerning situation is happening up and down the country. Is it not time that better safeguards for patient safety were put in place? Statutory regulation and the registration of healthcare workers could help. Many of them are now undertaking procedures that only doctors and nurses did but they have little training to do it.

[Lord Turnberg]

My name is attached to this amendment, which I believe is an extremely important one. I find myself in the somewhat unusual—indeed, unique—position of, for the first time, not being able to agree with the noble Lord, Lord Newton. We have had many debates in this Chamber in which the standards of care in our hospitals and nursing homes have been examined and, in too many places, found wanting. We have had many other reports showing the same thing. Many institutions and many care workers are outstanding but, as we know, there are too many places where patients are neglected and their basic needs not addressed.

Of course, all these failures cannot be put at the door of healthcare support workers. Where they occur, these failures are systemic and go right across the hospitals and homes. The employers, doctors, nurses and everyone in the institution should bear responsibility. However, all too often it is at the level of the healthcare support worker—who provides the basic care of feeding, washing, toileting and a host of other responsibilities and is often in closest contact with the patient—that we hear complaints from patients and their families. Healthcare support workers are at the end of the line and are too often left to themselves.

I fear that when we lost our SENs—our state-enrolled nurses, who did not need a university degree—in 2000, we lost a group of professionals who were trained and educated to do their job. If we are to regain the sense of professionalism and pride that my noble friend talked about that full registration would bring to a cohort of well trained and regulated young men and women, then we must move to full and proper registration. I do not believe that a voluntary register gives that degree of control. It certainly does not give sufficient recognition to the importance of the job. I hope that the Minister will agree.

[Lord MacKenzie of Culkein]

My Lords, I apologise to the House for not being here at the start of this amendment. Unfortunately, I had to seek the help of the health service this morning for a touch of bronchitis. I apologise particularly to the noble Baroness, Lady Emerton, for not being here on time.

I strongly support the amendment. I have spoken on this matter on each occasion that the call for statutory regulation has been debated in this Bill. I also referred to this issue in the debate on front-line nursing which we held last December.

The Government argue that voluntary registration is sufficient unto the day. I beg to differ strongly. As a nurse, I cannot agree that the present state of affairs should continue, and I do not think that I am a lone voice. The health committee in another place, the Nursing and Midwifery Council and all the staff organisations representing healthcare assistants all support statutory regulation.

History has a habit of repeating itself—wheels turn full circle. In the 1930s, financial pressures brought about huge increases in the numbers of support workers, or assistant nurses, as they were called. There was no provision then for regulation. It took the work of two committees—the Athlone Committee in 1937 and the Horder Committee in the early years of World War II —to lead to legislation which allowed for registered and regulated status for assistant nurses. We had state-enrolled assistant nurses as a consequence, and I think that it was in the early 1960s that the word “assistant” was removed from the title.

By the 1980s, the role of nurses on the first and second parts of the register was blurred. As a consequence, and as part of the move away from hospital-based training into higher education, the enrolled nurse training for first-level nurses was discontinued. It was always a mistake to leave that vacuum when the enrolled nurse training ended—a matter referred to by my noble friend Lord Turnberg.

The outcome is entirely predictable. That wheel has, indeed, turned full circle. We have had, again, huge increases in support staff; we have, again, financial stringency; and, as in the 1930s, there are now campaigns for proper regulation and training for those who assist nurses. However, the roles have been blurred this time not between the enrolled nurse and the registered nurse but between the healthcare assistant and the registered nurse. That is the very issue that led to the ending of enrolled nurse training, but this time there is no fall-back—there is no fail-safe for the patient—because there is no standardised training; there is no legal obligation in the Bill to require standardised quality training; and there is no obligation for registration, regulation, accountability and, not least, a code of conduct for support staff. The amendment in the name of the noble Baroness, Lady Emerton, will do much to resolve that issue. Most importantly, it is about patient safety. The amendment is specific—it is not about all support workers working in the hospital service or care homes; it is about those staff to whom are delegated what are, by any standards, nursing duties of registered nurses. It is not good enough for the Government to keep saying that voluntary registration is sufficient and that everything else is a matter for employers.

That is the present situation and it is far from satisfactory. I suggest that it will get worse in the future. We all know that the ratios between nurses and healthcare support workers are often worse than the generally accepted 60:40. The financial squeeze will certainly mean further changes—and not for the better. Voluntary registration does not work. For a long time, for example, clinical physiologists have been trying to make the case to the Government that voluntary registration has failed, and the coalition Government have turned their face. The leaving-it-to-the-employer approach will leave the patient at risk, and neither the registered nurse nor the healthcare support worker is protected in these situations if something goes wrong. Increasingly, the employer will be exposed as well, as there may well be more cases such as that of Mid Staffordshire as a consequence of financial pressures and getting skill mixes wrong—not least when these decisions are made by human resources people with little or no proper nursing input.

In my submission, the patients are not always clear about who is providing care for them. My recent six months as a patient in two teaching hospitals confirmed that—virtually everyone in a uniform was a nurse to most patients. That is not surprising. Healthcare assistants routinely carry out observation rounds; they carry out clinical procedures such as cannulation and catheterisation; they give injections; and they undertake venapuncture to take blood. That is just to name some of the procedures that they might carry out. Patients would be very surprised if they were told that the staff carrying out these clinical procedures were neither regulated nor registered.

Regulation and standardised quality of training does not, in itself, guarantee that matters will not sometimes go wrong. That can—and does—happen in all regulated professions. However, statutory regulation and registration is the best way forward to give better surety to patient safety. I strongly support these amendments.