Care Bill [HL]
Lord Turnberg Excerpts(11 years, 7 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Turnberg
My Lords, I strongly support my noble friend’s amendments, which would ensure that local authorities and, in particular, patients and carers can be represented on the LETBs. I have three amendments in the group. Amendment 38 adds to the list of bodies from whom LETBs need to seek advice—namely, the local university medical and nursing schools. I know it is hardly likely that their advice will not be sought since they are so intimately involved in delivering educational programmes, but in case that message is not clear, we need to have it clarified somewhere in the Bill. I recognise that there has not always been unlimited delight felt by the trusts about the way the universities, particularly the nursing schools, have provided education suiting their products to the trusts’ needs. Nevertheless, it would be clearly wrong to ignore them.
Amendment 41 draws attention to the need to include postgraduate deans in the local education and training boards’ activities. It surprises me, to say the least, that the deans are not mentioned at all in the Bill, despite the fact that they are absolutely crucial to the oversight of education and training. I am sure they will be involved but we must have the comfort of knowing that their crucial role is acknowledged by seeing them clearly mentioned in the Bill.
Amendment 50 makes it a requirement for LETBs to include in their list of bodies from whom they need to take advice, the local universities in their patch. It is not enough to include these bodies in the catch-all phrase of subsection (4)(e),
“such other persons as the LETB considers appropriate”.
The medical schools need to be named in that list.
Baroness Pitkeathley
I speak in support of Amendment 51 on the patient and carer voice. I know that there is sometimes resistance to patient and carer representatives on bodies such as this. One often hears professionals say, “They only speak from their own experience”. Yes, they do speak from their own experience—and that is actually the powerful and most informative bit. That is not to say that patients and carers can only speak from their own personal experience; they speak from the wider experience too of other patients and carers with whom they are in contact. That is the most important voice and we should give it a hearing, because very often it is a way of approaching a situation entirely differently from the way in which the professionals would come at it. I am sure that there is a great deal that most professionals, either trained or in the process of being trained, could learn from that.
Lord Turnberg
The problem is that I suspect there to be a conflict. There is a desire to devolve responsibility for education to local education and training boards, which are dominated, of course quite reasonably, by local providers. Their desire is to see a trained workforce in the right numbers, and they will be very interested in workforce planning. There is also a drive at the centre to maintain standards across the country, and so there is tension between the two. The noble Earl set out a number of provisions which will help. The amendments we put down were meant to strengthen that capacity in order for the LETBs to inspire confidence that they fully take account of educational standards and all that sort of thing, as well as the need to provide numbers of doctors, nurses, trainees and everything else.
Earl Howe
My Lords, I would rather have a creative tension than a disconnect. If we get this right the tension will be there but it will be mutually reinforcing. You will have accountabilities running in both directions, essentially, from the national to the local and from the local to the national. In the past this has been a notoriously difficult area to get right. We hope and believe that the structure we are putting in place, in which the LETBs are committees of the national body but which have their own autonomy to a certain degree, will ensure that the tension that the noble Lord referred to really is creative, rather than the reverse.
Lord Turnberg
My Lords, after that tour de force by my noble friend Lord Campbell-Savours, there can be hardly anyone who does not believe that the training of healthcare assistants should be mandatory. Indeed, most of the public would be surprised to know that they are not trained or may at least get through without any training whatever.
I strongly support the amendments. They are a slightly less strict version of Amendment 16 from the noble Baroness, Lady Greengross, in that it focuses heavily on the mandatory nature of the training, and that is of course the basic requirement. It omits the need for statutory registration, but the case for mandatory training is incontrovertible; I cannot see anyone believing that it is not.
I hope that the Government are open to this proposal. It is a valuable step in the right direction, even if we cannot have registration at the moment. I sincerely hope that the Minister will be open at least to this proposal, which has such merit and such strong support from almost everyone; I do not know of anyone who argues against it. I do hope that he might see this sympathetically.
Baroness Hollins
My Lords, my interest is as the parent of two adult disabled children who receive publicly funded care. I did not speak to the earlier amendment on the need for the regulation of health and social care assistants, but I strongly believe that some such staff are currently poorly served by the lack of an adequate professional framework. Many have poor pay and variable conditions of work, and perhaps poor protection for themselves. They also have varying access to training, supervision and education.
To give one example, a care assistant was employed to work with an autistic person without receiving any autism-specific training, even though it was specified in a support plan. One would hope for some basic mandatory training that also specified what future training might be needed to support specific people with specific needs. That seems to be common sense.
My noble friend asked clearly for mandatory training in basic standards of care, and that these candidates should then be registered as suitably trained. It is a neat solution to the problems that we are facing and it makes very good sense. I have one more example: in the interests of more integrated health and social care, care assistants are often required to support disabled or elderly people to access healthcare, but they are not very good at doing that. The confidential inquiry into the premature deaths of people with learning disabilities found that it was often the lack of persistence of people who were supposed to be supporting learning-disabled people that led to a failure in follow-through of their healthcare investigations and treatment.
I have a question about how personal assistants employed directly by people who are in receipt of direct payments would fare under such a system. Disabled people would need assurance that the personal assistant applying to work with them also had basic skills. One would hope that disabled people employing personal assistants would be reassured by the knowledge that someone had been registered as having a certificate of basic standards of care. I add my support to these very good amendments, particularly Amendment 23A.
Care Bill [HL]
Lord Turnberg Excerpts(11 years, 7 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Baroness Cumberlege
My Lords, I congratulate the noble Baroness on the enormous amount of work that has clearly gone into this amendment and on the way that she introduced it, drawing on a lifetime’s experience in this field. My one reservation is about having to consider what the fundamental purpose of Health Education England is. As I see it, if HEE works well, then in future it will be the engine that delivers a better healthcare workforce in England, thereby improving the quality of care for patients. It is responsible for the education, training and personal development of all NHS staff and for recruiting, from our schools and into our universities, suitable people to carry on these tasks within the NHS. It is employer-led and it is there to provide the right workforce with the right skills and values, in the right place and at the right time, to better meet the needs and wants of patients.
The NHS has more than 300 different specific jobs and more than 1,000 employers nationwide, and the workforce needs to be educated and trained to exacting standards. Its task now is to prepare students for a very different NHS in the future: more care out of hospitals, more focus on long-term conditions, greater integration of health and social care, and new technology and techniques, all of which require planning and changes to curricula, as well as more of a focus on student choice towards NHS needs. It has an enormously difficult and comprehensive job to do. As I understand it, Health Education England accepts and supports the concept of mandatory training for healthcare assistants and the introduction of some sort of certification scheme that would allow HCAs to prove that they had attained the required levels of education and training.
It is a matter for Parliament to decide a view on regulation that goes beyond that recommended by the Government, but I do not believe that Health Education England would be an appropriate regulator. It is not created to have such a role, and that would not sit effectively with its core role of education and training. Therefore, although I very much understand the spirit of the noble Baroness’s amendment and appreciate the knowledge that she brings to the subject, I do not think that HEE is actually the tool to do this with.
Lord Turnberg
My Lords, I, too, welcome the principle behind the noble Baroness’s Amendment 16 but I agree with the noble Baroness, Lady Cumberlege, that Health Education England may not be the right place for this. At various times in our debates I have banged on about the regulation of healthcare assistants, because not only would it reassure employers and patients that standards were being met but being on a register gives individuals a degree of self-respect and sense of identity and it boosts their morale. In a way, it is a pity that we got rid of state enrolled nurses some time ago when we moved to university-educated nurses. In effect, that has been very successful and nurses have done very well—they do a marvellous job—but we have left a gap where the SENs were.
Amendment 23, which moves slightly along this same route, may be as far as we can go but, if we do have mandatory training, that will inevitably mean that someone has to produce a register of those who have received such training. This may not be quite the right place for it but we might get there by another route.
Lord Patel
My Lords, I rise briefly to support my noble friend Lady Greengross. It is not that her sentiments about registration are not right but we debated this at great length during the passage of the Health and Social Care Bill and to a degree I felt that we lost the battle about registration then. What is now important is Amendment 23A, which, with all due respect, is a better amendment because it focuses much more on training and the responsibility of the employer. I agree with the noble Baroness, Lady Cumberlege, that HEE is not the right organisation to be a regulator of registration.
Lord Turnberg
“(b) the use of research evidence to ensure the rapid uptake of innovations into practice”
Lord Turnberg
This group of amendments, to which I have attached my name, is all about putting into practice the brave words we have heard about the need to place research at the centre of what the NHS does.
We have had the important and impressive inclusion in the NHS mandate to NHS England and CCGs of the duty to promote research, and we have had the recent publication of the Association of Medical Research Charities of a vision for research in the NHS with its three proposals. First, every patient should be offered the opportunity to be involved in research. Secondly, all NHS staff should be made aware of the importance of research. Thirdly, the NHS should conduct high-quality research and adopt innovation in healthcare rapidly. All the good intentions were spelt out in the earlier Bill and subsequently, but we seem to have lost sight of that in the current Bill.
Amendment 17 simply makes clearer what seems to be rather vague and perhaps less forceful in the current wording about accepting research evidence and putting innovations into practice. The Bill states that HEE must promote, which is a good word,
“the use in those activities of evidence obtained from the research”.
That has to be read several times to be understood. My amendment suggests something rather clearer, and what I hope is intended, which is,
“the use of research evidence to ensure the rapid uptake of innovations into practice”.
Amendments 20 and 32 aim to ensure that Health Education England also makes it clear that all who work in the NHS should understand and be able to play a part in research and innovation by including a new responsibility, to ensure that research and innovation are incorporated into the Bill. Amendments 37 and 39 point to similar responsibilities for the LETBs. My name is attached to these amendments, which are in the name of the noble Lord, Lord Willis, who unfortunately cannot be with us today because he is unwell. We wish him well. There is considerable danger that the LETBs in particular, dominated by local provider interests, will not unnaturally focus on their need to provide a clinical service and their requirement for sufficient numbers to fill their workforce needs. In so doing, they may not see that a service that is constantly evolving and changing needs a workforce that is fully switched on to the research agenda. They may not see that the future leaders of change—those who can undertake research and introduce new and better treatments year in, year out need to have their training needs met, too.
There are at least two types of need. The first is that of future academic clinicians, professors, senior lecturers, lecturers and the like in medicine, surgery, obstetrics and so on. The second is the need of all practising clinicians, be they doctors, nurses or technicians, if they are to integrate innovations and change into their practices. The academics need training programmes that are sufficiently flexible so that they can do their clinical training for some of the time and their research at others. They will almost certainly need to take three or more years out to do their PhDs, and they often need to do their purely clinical training over a longer period than others, as they slot periods of research into their clinical training.
Those going on to straight clinical practice—always the majority—need to understand what research entails, and will need to have some contact with research. Some may even take full time out for research, and in that way can appreciate new research findings as they come along. All those factors need to be considered by those in charge of education and training locally. I fear that unless something to that effect, as proposed in the amendments, is incorporated into the Bill, it will be so easy for it to slip out of view under the considerable pressure simply to provide services for today, with no thought for the needs of tomorrow.
I am not encouraged by the Department of Health’s document which is the mandate from the Government to Health Education England, in which the section headed “Flexible Workforce, receptive to research and innovation”—a brave heading—spells out what is intended. There is little here about how the intention of encouraging the development of a research-receptive workforce will be carried out. There is much about generalism, flexibility across service divisions and so on—all highly desirable—but nothing about producing those capable of doing the research and engaging in the clinical trials needed to make innovation possible. I hope these amendments will help to fill those gaps.
Lord Patel
My Lords, I support these amendments. My name is attached to Amendments 17, 20 and 32 in the name of the noble Lord, Lord Turnberg, and to Amendments 37 and 39 in the name of the noble Lord, Lord Willis of Knaresborough, who, as we have heard, was taken to hospital yesterday. I spoke to him in his hospital bed just before we started and he was beginning to feel better. I am sure we will want to wish him well.
I strongly support the amendment because, through the Health and Social Care Act, we gave prominence to the need to promote research and innovation in the health service, and it is right that we did that. It would be a pity now if the only gap in that duty would be for it not to apply to the key body, Health Education England, and the local education and training board committees. As the noble Lord, Lord Turnberg, so eloquently put it, the amendments are about education and training by research, and about making sure that LETBs also have a responsibility to make sure that they conform to the functions of the HEE. They are all related to research, training, innovation, continuing training and research and supporting research. They cannot be wrong and I hope the Minister will accept them. They are well meaning and promote research further.
Earl Howe
My Lords, there is no doubt that education and training can play an important role in creating a workforce that is research literate and innovative, with the skills required to diffuse the latest ideas and innovations. The noble Lord, Lord Turnberg, has focused our minds on some important goals in this area.
Through our investment in the education and training of health professionals, we must seek to ensure that our future practitioners know how to access evidence, use evidence and contribute to the national research enterprise. Developing a flexible workforce that is responsive to research and innovation is one of the key priorities that the Government have set for the Health Education England special health authority in its mandate. To answer the question posed by the noble Lord, Lord Turnberg, Section 63(1) sets out an objective for Heath Education England to support clinical academic careers.
Amendment 17 would require Health Education England to promote the use of research evidence to ensure the rapid uptake of innovations into practice. Amendment 20 would require it to exercise its functions to secure that research and innovation are incorporated into education and training. Amendment 32 would require it to have regard to the desirability of promoting research and innovation in clinical practice when performing its duties under Clause 85(1) to ensure sufficient skilled workers and Clause 87(4) when setting its objectives, priorities and outcomes for education and training.
The Government recognise very clearly the importance of promoting research and innovation. That is why Clause 86(2) of the Bill requires Health Education England, in exercising its functions, to promote research and the use of evidence from research in education and training activity. In response to stakeholder views in consultation and a recommendation from the Joint Committee that examined the draft Bill, we have strengthened the wording so that it is a duty to promote research. This has been welcomed by stakeholders such as the Academy of Medical Sciences and the Association of Medical Research Charities. It also reflects, incidentally, the equivalent duties to promote research already placed on the Secretary of State, NHS England and clinical commissioning groups by the Health and Social Care Act 2012.
The duty requires Health Education England to promote research activity in relation to its education and training functions, and the use of evidence obtained from that research, to secure continuous improvement in the quality of education and training. Those are pretty powerful provisions. I hope that noble Lords will appreciate from what I have said that Health Education England already has the necessary powers under Clause 86(2) to secure that research and innovation are fully incorporated into education and training.
I can reassure the noble Lord, Lord Turnberg, that Health Education England and the local education and training boards will work closely with research and innovation partners such as the academic health science centres and academic health science networks to deliver the duty to promote research. I can also reassure him that Health Education England will ensure that local education and training boards support this agenda and delivery of the duty to promote research. I hope that the noble Lord will feel sufficiently reassured by that to withdraw the amendment.
I shall now respond to the two other amendments to which noble Lords have spoken. Amendment 37 would add to a local education and training board’s main functions the promotion of research and the use of research evidence in the health service. Amendment 39 would require a local education and training board to support Health Education England in exercising its function to promote research into matters relating to social care services, primary care services and other health services so far as it is exercisable. I wholeheartedly agree that the local education and training boards need to take a strong interest in research and the use of research evidence when planning, commissioning and quality assuring the delivery of education and training. As noble Lords know, we have placed the primary duty to promote research on Health Education England but, as committees of Health Education England, the LETBs will be required to support the national body in delivering the duty through their workforce planning and education and training functions. Therefore, we do not see that the amendment is necessary in that sense. Health Education England will ensure that the LETBs support the delivery of key national duties, such as those in Clause 86, to promote research, support the NHS constitution and improve the quality of education and training. I also point out in this context that the appointment criteria that the Health Education England special health authority has used to appoint the existing 13 local education and training boards require the LETB to demonstrate effective mechanisms for partnership working with academic health science centres and academic health sciences networks.
I am sure that noble Lords will also be glad to know that Health Education England and the LETBs are working with the National Institute for Health Research, headed by Professor Dame Sally Davies, to ensure appropriate investment in education and training to develop clinical academic careers and increase the number of staff accessing academic careers programmes across all clinical and public health professions.
I hope that noble Lords will feel reassured that the spirit of the amendments is one which we have already grasped and which is reflected in the Bill and that they will therefore feel able not to press the amendments.
Lord Turnberg
My Lords, as always, the noble Earl gave some very reassuring words on this topic. I am not absolutely convinced that we do not need to strengthen the Bill a little more to reflect what he has enunciated, but, for the moment, I beg leave to withdraw the amendment.
Health: Degenerative Brain Diseases
Lord Turnberg Excerpts(11 years, 7 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
My Lords, I am aware that NICE co-operates with its counterpart bodies not only in Europe but in other parts of the world; its work has an international dimension. As the same time, I say to my noble friend that NICE is seen as a world leader in its field. Many other countries look to NICE for the methodology that it adopts.
Lord Turnberg
I am sure that the noble Earl is aware that Alzheimer’s disease is increasing in frequency as we all age, and is becoming a severe health problem. The Alzheimer’s disease association is certainly anxious for brains to be put into its bank, because it seems that there is the potential for a cure for this disease in a few years’ time. I suspect that the noble Earl is aware that the research that is done on these brains will be extremely helpful in that respect.
Earl Howe
My Lords, I absolutely agree with the noble Lord, Lord Turnberg. Dementia is of course a particular focus for research using brain tissue. Also, there are many other neurodegenerative diseases, such as Parkinson’s, which could potentially benefit from this kind of research.
Care Bill [HL]
Lord Turnberg Excerpts(11 years, 7 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Turnberg
“( ) HEE should seek the advice of those bodies concerned with setting standards for education and training, including the regulatory bodies and Royal Colleges.”
Lord Turnberg
My Lords, my name is attached to three amendments in this group, Amendments 9, 18 and 34. In this group of amendments I have tried to go a little further with my general theme of improving quality and standards.
Amendment 9 refers to the functions of Health Education England in Schedule 5, under which it will seek advice from relevant bodies. Amendment 18 refers to quality, improvement in education and training and the need for HEE to co-operate with relevant bodies. Amendment 34 refers specifically to those from whom HEE should seek advice. In each of those amendments, I am anxious that due weight is given to advice and co-operation with those whose sole reason for existence is to ensure high standards of education and training—the General Medical Council, the General Dental Council, the Nursing and Midwifery Council and the royal colleges. Those colleges, after all, set the curricula for all medical and nursing trainees and arrange all the exams and assessments.
For Health Education England not to have access to all that expertise, and potentially even to ignore it, seems to me unhelpful. Some indication about that is needed in the Bill. Therefore, I have included specific mention of those bodies here.
Lord Turnberg
I am extremely grateful to the noble Earl for his very full reply, and for drawing attention to the meaning of Clause 89, which I now understand more fully. In view of that, I beg leave to withdraw the amendment.
Care Bill [HL]
Lord Turnberg Excerpts(11 years, 7 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
The Deputy Chairman of Committees (Viscount Ullswater)
My Lords, I must advise your Lordships that if this amendment is agreed, I will not be able to call Amendments 2 and 3 because of pre-emption.
Lord Turnberg
My Lords, I will speak to Amendment 2. Before I do so, I should explain that I have heard from the noble Lord, Lord Patel, who cannot be in this place this evening because of illness in the family. I strongly support the amendments of my noble friend Lord Hunt, in particular the idea of a nurse on the boards; I also very strongly support his ideas on trying to attract good managers to stay in the service for as long as possible.
Amendment 2 is the first of several amendments that I have tabled emphasising the need for Health Education England and the local education and training boards to pay particular attention to the maintenance of standards and quality in education and training. I express my interests here as someone who has spent many years trying to raise standards of medical education in my previous jobs as dean of a medical school, the president of the Royal College of Physicians and, perhaps of equal significance, as president of the Medical Protection Society, where I was brought face to face with what happens when standards fail or are allowed to slip.
This amendment specifically concerns the membership of Health Education England and the need for it to include at least one person with expertise in research and another in education and training. I will save my remarks on research until we debate later amendments, but so far as education and training are concerned, my fear is that in the drive to meet workforce requirements and staffing numbers we will lose out on standards and quality. This amendment simply makes more explicit the need for input on the board of someone who has particular expertise about education and training, and the maintenance of standards.
I will make another point now to save making it later. I believe that there is a conflict, not easy to resolve, between the desire to provide sufficient numbers of trained staff locally—as determined, quite rightly, by local providers—and the need to maintain national standards. For example, in medicine it is vital that a cardiologist, orthopaedic surgeon, general physician or trained nurse is trained to a national standard that is recognised everywhere. It is not acceptable for a local provider to decide what training should consist of, but they want someone whom they can rely on. It is vital that there are national standards and hence there is a need for someone at the Health Education England level who has the expertise to look at how those standards can be set.
So far as national workforce planning is concerned, I have lived through innumerable efforts at medical workforce planning and found them to be fraught with difficulty, largely because it takes so long to train doctors: five or six years as undergraduates, then another five or 10 years of specialist or general training. Predicting need for different types of doctors 10 or 15 years downstream is far from straightforward. The noble Earl kindly sent around a document on a mandate from the Government to Health Education England. However, I fear that the section entitled “Excellent Education”, with its emphasis on training multipotential individuals working in teams across all health sectors—important though that is—de-emphasises the need for specialists. That prospect fills me with apprehension—that five years downstream we will have a health service lacking essential parts. I fear that the right balance between the need for general across-sector care and specialist care may be tipping too far in these particular aspirations. In any event, for the moment, I will press for the placing of relevant education expertise on the board of HEE, as suggested in this amendment.
Lord Willis of Knaresborough
My Lords, in the Second Reading debate on the Health and Social Care Bill, now an Act, I made the point that while we were talking about structures until the cows came home, the things that really mattered were the education and training of the staff within the NHS and the research element that gave those staff the very best tools in order to be able to care for patients and have good patient outcomes.
I compliment not only my noble friend, but the whole House, and indeed the whole Parliament, on the way in which it got behind the proposal in that Bill which is now in this one to create Health Education England as a way forward. The appointment of Sir Keith Pearson, who knows the supply side very well and has the ability to bring people together to listen to what he has to say and to be able to develop Health Education England as a real force for good, is quite outstanding. My worry is that we will start to bind the hands of Sir Keith and Health Education England, and we must not do that. What is required now is an organisation that is given sufficient flexibility and power to be able to grasp the key issues that are facing the NHS and to move forward.
I support very strongly the amendment in the names of the noble Lords, Lord Turnberg and Lord Patel, to include on the board people with relevant expertise. I am pleased that the noble Lord did not go on to say exactly who should be on that board, because I believe that that would be a step too far. But to have somebody with a real background in training, education and medical research would bring great strengths to the board.
I also support Amendment 3 in the name of the noble Lord, Lord Hunt. Indeed, I support virtually all the amendments tabled by the noble Lord and compliment him on the way in which he introduced this part of the Bill. Having a registered nurse on the board is so important. If we do nothing else in terms of the Francis report, the one thing that shines through is that you need somebody within the organisation who brings to the board those issues of quality care at every level. That is really quite exciting. I hope that my noble friend will listen to the wise words of the noble Lord, Lord Hunt, and others, and ensure that nursing is given a real place at the table, because quite frankly for generations it has not been. Nurses are no longer the handmaidens and “handmasters” of other professionals. They are in fact equals.
Lord Turnberg
Lord Turnberg
I will not move this amendment but I want to make one brief comment. If we are to rely on the regulations to interpret what clinical expertise really means, it is unlikely, however, that expertise in education and training will not be essential. I hope that comment will be borne in mind.
Care Bill [HL]
Lord Turnberg Excerpts(11 years, 8 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Turnberg
My Lords, when I spoke in the debate on the Queen’s Speech last week I concentrated on care of the elderly in the community which is one of the most critical issues facing society, as we have heard from some remarkable speeches today. If anyone has any doubt about the scale of the problem they will just have to read Hansard. I will not repeat what I said the other day, save to reiterate my specific plea that we pay attention to the screening of vulnerable elderly people in the community by primary care and social services staff so that we can introduce simple preventive measures to keep people at home. I hope the noble Earl might say something about that.
Tonight I want to concentrate on the proposals in the Bill to establish Health Education England and the Health Research Authority as non-departmental public bodies. These are, of course, extremely welcome proposals but inevitably there are a number of aspects where we need to seek clarification and improvement. The roles of the HEE and the associated local education and training boards—inelegantly abbreviated as LETBs—are spelt out in the Explanatory Notes but I fear that the Bill itself is fairly silent on how it will ensure high quality and standards in education.
For example, much is made of the fact that the LETBs are provider-led and dominated by the needs of NHS trusts for sufficient numbers and range in the workforce to meet those needs. So far so good, but what is missing is a proper recognition that the quality of training, the curricular content and the skills and knowledge of those going through training programmes will be taken care of. Where, for instance, is reference made to the need to include postgraduate deans on the boards of LETBs? It is not in the Bill and given only passing reference in the Explanatory Notes. Where is reference to the need to engage closely with local universities or training colleges—that is, with those whose whole raison d’être is education and all that that entails? Content of training programmes and maintenance of standards is their special expertise and for providers to ignore that aspect will be to their detriment. I am sure they are aware of that but we need mention in the Bill of a need to involve universities, either in the membership of the board, albeit in a minority, or, if not that, then an obligation to seek their advice in formulating their programmes of training.
At the national level, in the HEE, there is some recognition in the notes to the Bill, but not in the Bill itself, of a need to seek advice from the royal colleges—here I have to express my interest as an ex-president of a royal college—the GMC, the GDC and the NMC in developing its policy. It seems to me that all those bodies have considerable expertise in education and training. Indeed, the main functions of the medical royal colleges, for example, are in the development of all the curricula for medical trainees and in setting their exams and assessments to make sure that they have reached an acceptable level of skills, aptitudes and knowledge. Every cardiologist, orthopaedic surgeon and psychiatrist has to go through a training programme devised and run by a royal college. The regulatory bodies have responsibilities for the oversight of training and education to ensure that it is fit for purpose. Yet despite all this remarkable body of expertise, no mention is to be found in the Bill that the HEE will draw on any of this for advice and assistance.
Then there is a further issue of the need to take account of the importance of clinical researchers in programmes of training and education. We have heard much helpful comment from Ministers about the need to embed research in the NHS and to make every health professional a researcher and every patient a willing participant. The noble Earl was extremely helpful in getting research high up the agenda for the NHS in the Health and Social Care Bill. It is, of course, through research that we may in due course find some answers to the major diseases from which we suffer such as dementia, diabetes and Parkinson’s, so it is vital that research really is in the middle of the NHS.
While the new Bill is very helpful in stating that the HEE must promote research into matters relating to its activities, which is rather subtle, it hardly takes account of the need for LETBs to take account of this in their training programmes. Those embarking on a clinical academic career have to be able to take time out from their purely clinical training to train in research, perhaps for up to three years if they are going to do a PhD. All other trainees, at least in medicine, need to be able to carry out some research so they have experience of what research is about. They are then in a better place to take advantage of the results of research and not resist the rapid introduction of innovations when they go on into practice. I fear that the dominance of provider-led interests in LETBs will lead them to paying little attention to this aspect of training unless they have access to advice from their local universities and the research community. I fear very much that the shadow body of the HEE has shown little sign so far that it is aware of this particular point.
I come now to the Health Research Authority. I believe we are extremely fortunate in having Professor Jonathan Montgomery as its first chairman. He is clearly switched on to the need to be able to protect the public and the patient interest, while at the same time encouraging high-quality clinical research and not putting unnecessarily burdensome regulation in the way. It might be thought that these twin responsibilities—the need to protect patients and ensure their safety and confidentiality on the one hand while promoting and encouraging research on the other—are opposed to each other but they are closely aligned. Patients want not only to be safe but they are very keen for research to be done on their diseases. Furthermore, surveys of patients’ attitudes show that more than 90% of patients want to be involved in research themselves in clinical trials. They are desperate for innovations in treatments arising from research to be applied to them. Of course they want to be safe and protected but they also want high-quality research, so the two go hand in hand. It is pleasing to know that Professor Montgomery is well aware of this and the need for proportionality in regulation.
I welcome the clear statements in the Bill on this and in particular in Clause 98(3) where it is proposed that the HRA must promote standardisation of the regulation of research across England and ensure that such regulation is proportionate. It is clear, too, that for the HRA to gain credibility with the public and patients it cannot simply pontificate about safety from on high. It must actively communicate with the public and have processes in place for it to be able to listen to the views of the wider public. It needs access to the public view and should put in place mechanisms to achieve that.
I come now to another aspect of transparency. In addition to its own transparency, the HRA should also be encouraging transparency of researchers engaged in clinical trials in academe and industry and their results should be published as expeditiously as is reasonably possible. Results should become freely available, after careful checking for reliability, whether they are positive or negative. It is helpful to know that GSK is leading the way in industry by publishing its data more openly and others are beginning to follow. We do not want the HRA to be given too rigid a formula. That would be counterproductive, but we do want to be able to encourage and support the HRA in its efforts to use measured persuasion.
Finally, it is good to see in the Bill the confirmation that the HRA will continue its good work in co-ordinating the work of the ethics committees and in taking on the roles provided until now by the Secretary of State and what was PIAG in ensuring the safe use of patients’ data. It is gratifying to know, too, that the HRA is moving towards a single application process for entry into the jungle of research regulation. There remains at least one major barrier to research and that is the local R&D approvals that have to be given by each trust where clinical trials are being done. This is where we need a rational, proportionate and national system and if the HRA can incorporate trust R&D approval into that national scheme, the research community would heave an enormous sigh of relief.
I hope I have not given the impression that I am unhappy with this part of the Bill. I think the proposals to set up HEE and the HRA are extremely valuable but of course there is always room for some improvement.
National Health Service (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013
Lord Turnberg Excerpts(11 years, 9 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Turnberg
I am delighted to be able to follow the noble Lord, Lord Owen. He puts his finger on it. It is hard not to think that we are coming up against some rather polarised views lying behind this debate about how far we can go with the use of private providers in the NHS. On the one hand there are those who believe that private providers will drive up quality and efficiency by the competition that they introduce, and on the other those who see private providers in it for the profit that they will make from the NHS.
Clearly I cannot go into this tonight but I want to say two things. First, we have an NHS for which everyone pays through tax for the common good and which distributes resources to those who need it so that society as a whole can benefit. By opening up the NHS to private companies we are increasingly using that taxed income to provide for, among other things, their profits. When we go down that route we have to be sure that we are getting something that is worth while for society and that we have the balance right. Secondly, I have the feeling that instead of the welfare state, to which we are all signed up, being regarded for the common good, it seems to be increasingly regarded, in some quarters at least, as a cost to society and an onerous subordinate to economic policy. This is not a debate for today, although we need to have that sort of debate. It does, however, colour my views about this contentious set of regulations.
According to the wording of Regulation 5, as we have heard, commissioners are legally obliged to go out to tender unless they are satisfied that services can be provided only by a single provider. Despite the reassurances by the Minister and his colleagues, the wording here is so unambiguous that a number of distinguished lawyers tell us that there is no way out of having to tender for everything else. The fact that the Government’s lawyers are able to come up with a different conclusion, as I am sure the Minister will tell us, suggests at least that there is room for confusion and for something that would have to be tested in the court, and no doubt the courts will pray in aid the EU competition law.
I am most concerned about the problems that this tendering process will cause, as are the many organisations that have written to us. For example, if we look at where the most severe difficulties lie in the health service and try to think what tendering from a variety of providers might do to resolve them, we come up against a major barrier. It is in the care of the elderly, of those with long-term multiple illnesses and of those with mental illnesses that we are clearly failing in the NHS. Yet those are the services that private providers as well as insurers are least likely to want to take on. They are much more interested in aspects of care that come in neat packages—short-term items such as cold-planned surgery or investigation that are readily costed and charged for. But these are the sorts of care that by and large the NHS is pretty good at. It is here where the cherries lie and which private providers will try to pick, leaving longer-term care for the less glamorous, chronically ill elderly and the mentally ill to the NHS. It is not a future that many in the NHS are likely to welcome.
This says nothing about the administrative costs of this tendering and contracting, which will not be trivial. It says nothing about the barriers that it will throw up to the integration of care across several disciplines, which is already quite difficult to achieve. Will multiple providers make it easier or more difficult for integration? I cannot see it.
For these and the many other reasons that other noble Lords have raised, these regulations are a distraction designed to maximise private sector involvement and leave far too little room for commissioners to be sensible and flexible in their approach. They should be removed entirely, and if that is not possible they should be reworded to make it absolutely clear to commissioners and everyone else that what Ministers are telling us is also written clearly on the tin.
Lord Howard of Lympne
My Lords, I declare my interest as chair of Help the Hospices, and in a moment or two I shall put the remarks of the noble Lord, Lord Owen, in context. However, I shall begin by correcting a report that appeared in the Financial Times last week, which said that Help the Hospices and other charities regard these regulations as a fresh attempt to privatise the National Health Service. I cannot speak for the other organisations, but that is not the way that we at Help the Hospices look upon these regulations.
The original regulations gave rise to considerable concerns, and I pay tribute to the Government for being prepared to listen, to think again and to revise the regulations. The revised regulations go some considerable way towards allaying those concerns. They do not go the whole way, and the noble Lord, Lord Owen, identified some of the concerns that remain, but we believe that those concerns can be met not by annulling these regulations as the noble Lord, Lord Hunt, seeks to do this evening, but by ensuring that the guidance which the Government intend to provide removes any ambiguity and removes the dangers to which the noble Lord, Lord Owen, referred.
The noble Lord and I have long experience in different contexts of the difficulty of covering every contingency in the wording of regulations, of getting the wording of regulations absolutely right and avoiding any degree of ambiguity. The previous speaker, the noble Lord, Lord Turnberg, recognised that the Government’s legal advice was such that the fears that have been expressed simply would not arise if these regulations were properly interpreted. Monitor, which is to give the guidance that we await on the way in which these regulations are to be interpreted and implemented, has a very important role in that respect and will consult before issuing that guidance. We at Help the Hospices intend to take full advantage of the opportunity which that consultation affords to ensure that Monitor gets the guidance right, removes any ambiguity and ensures that any lingering concerns that we may have do not turn into reality.
It is true that the changes that are taking place in the National Health Service in the way in which we provide health services in this country pose a certain danger to voluntary organisations such as the hospice movement, but not because the Government intend to do any damage to the hospice movement, as was made clear to me and some of my colleagues from Help the Hospices when we had a meeting with the Secretary of State very recently. The danger lies in the law of unintended consequences, so it is right that we should be vigilant to ensure that those unintended consequences do not damage hospices that do such wonderful work and provide such remarkable care to those who are near the end of their life and benefit from the care that hospices provide. I am satisfied that that danger in this context can be averted by sensible and proper guidance from Monitor, and I hope that at the end of this debate the Minister will give the House some assurances about the nature of that guidance which will put to rest any lingering concerns that might exist.
Health: Cancer Drugs Fund
Lord Turnberg Excerpts(11 years, 10 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Earl Howe
My Lords, we consulted on our proposals for value-based pricing between December 2010 and March 2011, and as part of that process a number of patient organisations contributed their views, which were reflected in the Government’s response to the consultation, published in July 2011.
Lord Turnberg
My Lords, what will happen to the panels of cancer experts that gave such valuable advice to SHAs about which drugs should be provided?
NHS: Mid Staffordshire NHS Foundation Trust
Lord Turnberg Excerpts(11 years, 10 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Turnberg
My Lords, I, too, thank the noble Lord, Lord Patel, for introducing this debate with his usual panache.
As Roy Griffiths said in 1983, when he was looking to change the management structure of the NHS,
“if Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge”.
I think she would have been more concerned today about finding someone in charge of the care of the patients in the corridors of the Mid Staffs hospital. She would have been looking for anyone able to explain what had been happening to the patients for so long and would have found no one.
The Francis report outlines a huge number of recommendations that include changes in the culture and much about policing the service to detect poor behaviour, but to my mind, beefing up the complaints system, while very important, comes a bit too late. We need to think more about preventing the need for the complaints, and there is one crucial omission; while there is a strong focus on the responsibilities of the managers and the board, none of these people, try as they might, can be on the wards all the time, every day of the week. They visit from time to time. The doctors, too, come and go as they rush to their clinics or operating theatres. The people on the wards all the time are the nurses, and this is where we have to focus hard.
I am in no position to criticise the nurses themselves—they do a fantastic job, and I have personal reasons for being enormously grateful for what they do. My aim in pointing at the nurses is much more to do with the way in which nursing careers are organised. This is where I believe some changes are needed. We need to bring back the old-style career-grade sister who was in charge of the ward. Many years ago when I was a young doctor—I am sorry that I sound like an old fogey—the sister in charge really was in charge. She was usually a mature woman—there were few men in those roles—and she ran her ward with a rod of iron. Both the patients and the doctors ran scared and were loath to cross her, but she knew everything about every patient, and the doctors relied on her implicitly. She would not have countenanced the sorts of behaviour that were described so vividly in the Francis report.
What has happened to that post? Now the role of ward sister is not regarded as a career post at all. It is simply a rung on a ladder, and after a year or so they are promoted to teaching or more managerial roles. It is just a stepping stone to bigger and better things that are not so closely engaged with the patients.
Consultant friends tell me that it is unusual for them to find a nurse, let alone the sister, to accompany them on their ward rounds, or indeed to find anyone to tell them what has been happening to their patients. The solution, to my mind, is not the heavy hand of top-down monitoring and punitive complaints procedures, but the placing on each ward of sisters or charge nurses in clinical career posts—I stress clinical posts—who are given full responsibility for what goes on in their wards and are awarded accordingly. My view is that they should be given exactly the same salary as a consultant, since that would be commensurate with their level of responsibility. It would be a post that commands all the respect that you would expect of someone in such an important position. I recognise that this idea might not meet with the approval of the nursing professional bodies, but I ask the Minister to consider this proposal sympathetically. It seems to me to be the only way in which Florence Nightingale and her lamp may be able to find someone in charge of the patients’ well-being.
Care Services: Elderly People
Lord Turnberg Excerpts(11 years, 10 months ago)
Grand CommitteeRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Turnberg
To ask Her Majesty’s Government what steps they are taking to improve care in the community for elderly patients.
Lord Turnberg
My Lords, I am grateful for the opportunity to open this debate, even though I suspect that many noble Lords might share a faint sense of déjà vu about this topic. However, the fact that care in the community keeps reappearing on our agenda suggests that, despite numerous impressive reports and repeated debates in this House, we are not yet anywhere near solving the problems.
I suspect that few here will admit to any ignorance of the facts, so I hope noble Lords will forgive me if I start by reiterating the nature of the difficulties we face. It may save others having to repeat them. First, the country has entered a prolonged period of severe economic constraint, so there is little new money available centrally. Secondly, we have no control over the demand for social care that is growing at a remarkable rate.
The population is ageing as life expectancy goes up in an inexorable straight line. The current 3 million people over the age of 65 will rise to almost 5 million in the next 20 years, while the number of over 85 year- olds will double from 1.3 million to 2.6 million. We would celebrate this extension of life were it not for the fact that the number with multiple chronic diseases will also increase by about a third, while the number of those with dementia is set to double from the current estimate of 800,000. If that is not enough to frighten you, there is the statistic that one in three people over the age of 85 will develop dementia. That is what I am told. Many of these people end up in an acute hospital, the place least suited to their needs, and the number lingering there unnecessarily is huge. Of the over 85 year-olds admitted, some 140,000 stay for more than 30 days, and the numbers are rising. A diagnosis of dementia is the primary reason for admission in some 55,000 patients a year, in the majority of whom the diagnosis had not been made before admission. Where, I wonder, were the GPs?
These patients are admitted, but too often there is nowhere else for them to go. Social services departments are sorely underfunded and about four-fifths of local authorities are now said to be restricting social care to those with needs graded as substantial or critical. There is a black hole of some £16.5 billion looming in social care funding over the next few years. The gap between the money needed to meet demands and that available is growing year by year. Here we have the nub of the problem—increasing demand from an ageing population acquiring multiple long-term illnesses and a veritable epidemic of dementia, together with social services departments stretched way beyond their capacity now and with a future in which they will be unable to deliver even the basics of care, and all against a background of severe constraints on the money available from government.
We cannot simply go on as we are and try to patch up the current system of an NHS designed for acute hospital care, essential though that may be, while the desperate need is for prevention and the long-term care of the elderly. We must start now to develop a long-term plan to meet these problems. My first question to the noble Earl is: is there any sign that the Government are thinking along the lines of long-term future planning?
At the end of the day, we must ask ourselves where the money is to come from. Of course, some measures could be taken that would help a little. The poor co-ordination between care workers in hospital and in the community has been resolved in a number of well recognised places around the country and more should be done to spread that good practice. Of course, there may be efficiency gains to be made somewhere in the system. Then there is the recent government initiative in the wake of the Dilnot report to help the elderly pay for their care. Will that ease the financial burden on local authorities? I fear not, because although it offers some help to the elderly themselves, it seems more likely to add to the problems of local authorities than to help them.
Then there are the usual calls for funds to be transferred from the supposedly cash-rich NHS to social services. I am very supportive of proposals that NHS and social service budgets should be pooled to fund care for the elderly. That makes a lot of sense and I was happy to see something along those lines in Andy Burnham’s recent speech about a future Labour health policy. We need to think, too, not only about merging budgets but also medical and nursing staff so that they can work across the boundaries between hospital and community. We also need to look critically at how we can incentivise and support GPs who are really the key players in the community. It is far from clear whether they are prepared in the CCGs for commissioning long-term care. Will the noble Earl tell us whether any attention is being focused on the role of GPs there?
What about closing hospitals or beds and transferring the savings? Data showing that up to a third of acute hospital beds are occupied by patients who should not be in hospital at all provide ammunition for those who see considerable savings from cutting bed numbers. That is not easy. If we try to go along that route, we have to look at where the costs of acute hospitals really lie. They lie largely in the staff and relatively less in the number of beds. The workload for the medical and nursing staff of acute hospitals is not determined by the number of beds, or even by the number of long-stay patients, but by the rising tide of acute emergency admissions. It is hard to escape the conclusion that we are not well off in NHS hospital services. Hardly a day goes by when we do not hear of failings in the care of the acutely ill.
If wards or even whole hospitals were to close, that acute workload would not diminish. Indeed, the more rapid throughput of patients through a smaller number of hospital beds would increase the intensity of the work. I am not saying that there would not be any savings made on, for example, heating and lighting bills and perhaps on administration, but the savings to be made, especially on doctors and nurses, would be rather less than one might hope. That may account for the intriguing piece of research evidence from Julien Forder, who published a paper in the Journal of Health Economics in 2009 in which he showed that for every pound spent on community services it was possible to save only a third of a pound on hospital services. Caring for someone in the community is not a cheap option.
Meanwhile the NHS itself is under remarkable cost-saving pressures as it seeks to answer the Nicholson challenge. Hospitals are barely coping in many instances, and the prospect of diverting even more funds is likely to be impossible to bear. I am not suggesting that rationalisation of services into a smaller number of specialised centres is not a good thing—it clearly is—but closing acute hospitals to save money simply to transfer it into the community does not bear too close examination. In any case, there are the calculations suggesting that there will be a shortfall in NHS funding of some £30 billion per annum by 2020 on current trends, so the question remains: where will the funds for social services come from? It is difficult to see much coming from simply integrating NHS and social service budgets, desirable though that may be. Simply pooling two inadequate sources of money does not sound like an answer to me. We have to face the idea that the Government of the day, whoever they are, will have to give a higher priority to care in the community than they have currently been able to do. It is a political decision, and we must think more broadly than simply within the box of the Department of Health.
Are there are any discussions going on between government departments— housing, transport and so on—on plans for future care in the community? How much priority are Governments as a whole willing to give to this compared, for example, with a high-speed train or nuclear submarine, desirable though some may think they are? Do they have a higher priority? These are decisions that only a Government have to face. I do not envy them for that, but in a democracy such as ours I do not believe it is entirely wishful thinking to feel that a clear majority of the population would strongly favour a diversion of resources to areas that they think are of high priority, and I can think of few higher priorities than the way we care for our elderly.