Health: Confidential Patient Information

Lord Willis of Knaresborough Excerpts

Thursday 23rd January 2014 Lords Chamber

[Earl Howe]

My Lords, everybody in the country has a right to object to their data being shared. Those objections will always be respected. A practical way had to be found to enable that process to happen, and we believe that it is not unreasonable to expect a patient to have a conversation with their GP. I will, however, take the noble Baroness’s suggestions on board and feed them in.

[Lord Willis of Knaresborough (LD)]

Does my noble friend agree that while patients can object to having their records sent, they cannot, in fact, legally prevent the GP sending those records to the central repository? It is at that point that the discussion as to whether those records should be sold on and used by pharmaceutical companies and others is important. Does he agree that it is important that companies carrying out research into new drugs and compounds can access patient records, because they are an important dataset for making sure that we have better healthcare for our people?

[Earl Howe]

My noble friend is correct. The UK has a unique advantage in being able to link patients’ data records for the purposes of research and for effective healthcare commissioning. It would be extremely concerning if European law prevented that. I believe and hope that patients will be encouraged that there will be no abuse of identifiable information. The controls around this are very strict and, in the main, only anonymised data are required for research purposes.

Professional Standards Authority

Lord Willis of Knaresborough Excerpts

Thursday 7th November 2013 Lords Chamber

[Earl Howe]

My Lords, I agree with the noble Baroness, and I pay tribute to her work as chair of the PSA. The benefits of accredited voluntary registration are clear. The point is to give the public, employers and commissioners choice to use people on a register that the authority has independently assessed and approved, and only those registers that the authority has accredited are allowed to use its kitemark.

[Lord Willis of Knaresborough (LD)]

My Lords, the 2013 annual report of the Professional Standards Authority states that its third strategic objective is to:

“Enhance public confidence in unregulated health and care occupations”.

How many voluntary registers of healthcare support workers are now registered with the standards authority, how many individual staff do they cover and how can the public get access to them? How long does the Minister expect it to take for all healthcare support workers to be registered, as the recent reports following the Mid Staffs inquiry suggested?

[Earl Howe]

My Lords, the Francis recommendations made no reference to voluntary registers for healthcare support workers. The broad position is that the PSA has not received any applications from organisations holding voluntary registers for healthcare support workers, and therefore no voluntary registers for healthcare support workers have been approved. As accredited registers are voluntary, I am afraid that the Government are not in a position to predict how long it will take for all healthcare support workers to be registered.

Care Bill [HL]

Lord Willis of Knaresborough Excerpts

Monday 21st October 2013 Lords Chamber

[Lord Willis of Knaresborough (LD)]

My Lords, I am delighted to follow the noble Baroness, Lady Emerton. May I say—not as an aside but as genuine comment—that we are all in awe of her commitment to nursing and the care profession? It is not just eight weeks, but a lifetime of commitment. I think the whole House is enormously grateful for the contribution she makes.

I rise to support Amendment 144 in the name of the noble Lord, Lord Hunt, having first thought that it was not required. It seems fairly obvious that the Care Quality Commission shall, in carrying out its functions,

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

The idea that any inspector or regulator would look at the guidance and then apply that as criteria would seem an absolutely normal process. Yet on reflection, having read the Francis report and the Winterbourne View report, one suddenly realises that, certainly from 2009 but far back in time as well, the department under successive Governments has offered guidance about safe staffing levels. It has done that in everything, but particularly in acute settings, I appreciate that. The fact that that was not taken into consideration makes the noble Lord’s amendment absolutely appropriate. I cannot see for the life of me why my noble friend would not accept it as a very sensible addition for making sure that the CQC, when it carries out inspections, takes that into consideration.

I would like to spend a little more time on Amendment 159, which has been so superbly introduced by the noble Baroness, Lady Emerton. Amendment 159 covers a lot of the same ground but goes further in spelling out the direct link between staffing and patient safety. It is important for my noble friend to understand what it does not do; nobody on either side of the House has sought to impose statutory staffing limits in legislation. That would be counterproductive in getting the sorts of outcomes that we want.

I prefer, as I am sure colleagues on all sides of the House do, to have strong statutory guidance with good inspection, which is what we have had in the past. The amendment of the noble Lord, Lord Hunt, does this—it completes the circle. I am very concerned that this House and the department spend too little time addressing the question of safe staffing. What does that actually mean? I declare an interest as an honorary fellow of the Royal College of Nursing. The RCN associates safe staffing with nursing because nurses, together with healthcare assistants under their supervision, do most of the care. But safe staffing is about the total product, not simply about nursing. It is also about the ward managers and everything else that goes into ensuring that when patients go into any setting, whether it is domiciliary, a care home or an acute hospital, there is an appropriate level of staffing.

When I was writing the Willis Commission report last year, one of the things that came up over and over again was a demand for mandatory staffing levels. I spent some time looking at the literature on safe staffing levels to see whether there was a correlation between having the right number of staff—registered nurses, care assistants, doctors or consultants—and outcomes. Frankly, it is very difficult to find empirical evidence to support it one way or another, simply because nobody in the healthcare system works in isolation from their colleagues. You are only as good as the team that works around you and their skills and training mix. I looked up what was happening in California where for more than 10 years they have had mandatory staffing levels for registered nurses. No other state has followed that. In April Senator Barbara Boxer introduced a Bill in the Senate to try to establish a federal system of ensuring that all hospitals had particular staff levels but nobody has followed that through.

There is some research being done in the UK, such as Anne Marie Rafferty’s 2007 study, with which Members are familiar. It was a really good piece of work which showed a 26% higher mortality rate in the cases of very high patient to nursing ratios. Kane’s meta-analysis in 2007 of all the literature indicated an emerging consensus that there are particular staffing levels beyond which the situation becomes dangerous. It is an issue for the department to constantly keep that under review. The amendment does not go over that ground but makes it clear in terms of safe staffing that there would be a duty on the provider, such as the hospital or the care home or those providing domiciliary care, to ensure that staff levels were appropriate and that staff competence is such to carry out safe care. After all, there is nobody in this House who does not want to see safe staffing within all NHS and other providers of health and care. That seems to be a basic starting point for a high-quality health and care system. We need to be able to ensure that that is the case. You will only find out what safe staffing levels are in a particular scenario and setting if you monitor them. That is why there is a requirement in the amendment to report on it. We are not talking about a report every three or five years, but there should be a continuous report so that when the CQC goes into a setting, it can look at the correlation between safe staffing levels, acuity and mortality rates and other factors, to see whether outcomes are dependent on particular mixes of staff.

Nor is the amendment saying that there should be annual reports. The Secretary of State would decide how often the department should be able to look at those reports. In essence, however, we are trying to establish that ensuring that the staffing mix is appropriate to the setting and to the patients who are being cared for is fundamental to healthcare. I hope that the Minister can give us some serious comfort on that. If we can get that right, we will have a good healthcare system.

[Baroness Gardner of Parkes (Con)]

My Lords, I am of course impressed by what has been said by the noble Baroness, Lady Emerton, who always knows so much about this subject. We have benefited from her great expertise over time. I am also interested in what the noble Lord, Lord Willis, has just said on the same amendment; he cited Amendment 159 but I thought it was Amendment 158.

[Lord Willis of Knaresborough]

It was Amendment 159.

[Baroness Gardner of Parkes]

I leave it to the department to work out whether it was Amendment 158 or 159, but that is not too important.

In many ways Amendment 144 does not go far enough. I am sure that the point of the noble Lord, Lord Willis—that the Care Quality Commission should be capable of thinking of these things for itself in any case—is right. However, the phrase “the skills mix” concerns me. There can be huge differences in the skills mix. I was concerned that the Chelsea and Westminster Hospital, having waited for perhaps as long as 10 years, at last got a specialist nurse for neurological conditions. The hospital was delighted because it had had huge demand for such a service. I am a great supporter of specialist nurse services.

The Royal Free then came along and poached that nurse from the Chelsea and Westminster, which then looked at what it could do. I was informed by word of mouth that there was no question or even thought of a replacement because there was a long list, and it was a case of “the first cab on the rank” as to who was deemed to be most needed. It could have been an ordinary nurse, it could have been a surgical nurse or anyone. You moved on and did not replace the person with the skills that you needed and wanted. You had to replace your missing person with whatever the next thing on the waiting list was. That seemed to be a serious cause for concern.

It is essential to know what skills mix is needed. The amendment mentions “official guidance”. It would have to go much wider than official guidance. It has to be attributable to the particular hospital or service that is involved. Although the amendment covers many of the important points, it does not cover the need for every facility to have cover within that department and not to then find that they have lost it because someone left—they could have gone off on maternity leave, they could have left for any reason, but in this instance they were poached by another NHS hospital.

Whatever the answer, it is important. The relationship between the staffing levels is hard to assess and has to be individually done. The Care Quality Commission should be capable of having an indication of what it should be looking at, and needs to be aware of all these problems. Of course, not one of us could oppose having enough staff on the wards, which the noble Lord, Lord Hunt, said was necessary. However, we are now faced with positions where budgets are limited and they have to look at and work out what they need most. I do not agree at all that it should be just a progression from whoever has been waiting the longest; it should be whatever the hospital, or a particular department, needs the most. Although I support the principle, perhaps it needs more than this. I am hoping that the Minister will be able to assure us that he can incorporate some words within those he already has to make it clear that there must be this obligation. I strongly support Amendment 144 and I am open to conviction about Amendment 158 or 159.

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[Earl Howe]

My Lords, I hope that I can give noble Lords considerable reassurance on the Government’s position on these important issues. It is almost axiomatic that safe, high-quality care is dependent on people and that right-staffing, in terms of numbers and skills, is vital for good care. The importance of having the right staff with the right skills and in the right numbers is central to the delivery of high-quality care. Where staff are stretched because they are too few in number, corners will be cut, with inevitable adverse consequences for patient care. Equally, where staff do not have the right skills to carry out their tasks, the quality of care will suffer.

Patient safety is the first priority, and safe staffing levels really matter. The quality of care provided to patients is ultimately the responsibility of the leadership of provider organisations. It is their responsibility to ensure that they have the right staff with the right skills in the right place at the right time in order to provide high-quality care. In the final analysis, it is for hospitals themselves to decide how many nurses they employ, and they are the best placed to do that. Nursing leaders have been clear that hospitals should determine and publish staffing details and the evidence to show that staff numbers are right for the care needs of the patients that they look after.

Although local providers are best placed to do this based on local need, we expect them to look to authoritative guidance and evidence-based tools and learn from best practice to deliver cost-effective and safe care. We recognise that there is a need for national action to ensure that local organisations meet those expectations. As a result of the national nursing and midwifery strategy and vision published in 2012, Compassion in Practice, a considerable amount of work is going on across England to ensure that providers use evidence-based tools, using acuity and dependency measures to set staffing levels, and for boards to publish these staffing levels on a regular basis.

I want to explain what we are now doing to build on that work. First, the Chief Nursing Officer, supported by the National Quality Board, is developing guidance for the system, including a set of expectations, to support provider organisations in securing the appropriate staffing capacity and capability for nursing, midwifery and care. This guidance is being developed with the intention of ensuring safe patient care and that patient outcomes are not compromised. It will include expectations on transparency and publication of information on staffing.

This guidance is being developed jointly by the statutory organisations responsible for quality across the NHS, which are brought together as part of the National Quality Board and which include the Care Quality Commission, Monitor, the NHS Trust Development Authority and NHS England. It will be published next month. I can therefore only agree with the intention behind the amendment that providers need to be open and transparent about their staffing numbers. The positive news is that action is already in place to ensure that this happens.

[Lord Willis of Knaresborough]

What my noble friend has said is incredibly encouraging. However, before he leaves that point, could he take up the very important issue raised by the noble Lord, Lord Warner? This is not just about hospitals; it is also—particularly in my case—about care homes and other community settings. Will the regulations apply to all those settings, so that we get continuity throughout the system?

[Earl Howe]

My Lords, I am happy to come to that point. The short answer is that that is certainly our intention.

I turn to Amendment 159, about which I will be a little critical. We consider that requiring health or care service providers to,

“publish a report containing staffing levels based on evidence of safe staffing levels supported by acuity and dependency levels for each patient”,

is really not a viable alternative to what we are already putting in place and would not work in practice. It would be burdensome to implement in precisely that form and could detract from the ability of staff to deliver good clinical care.

I understand, of course, the thrust of the thought behind the first part of the amendment, which says that,

“the first duty that a health or care service provider must consider for any decision is patient safety”,

However, it carries the risk of unintended consequences. It could lead to other important factors, such as innovation and service improvement, not being given sufficient weight and providers becoming unduly risk averse. We need to reflect that any innovative treatment—which we want to encourage in the health service—carries some risk. That is always justified by benefits for the wider system. We do not want clinicians to become reluctant to take risks if this amendment were passed.

Also, we do not feel that specifying report requirements for provider boards is the role of the Secretary of State any more. Rather, the focus has to be to allow for local accountability and local decision-making. However, as I have said, we recognise that decision-making tools are needed and I agree with my noble friend Lord Willis about that. We are working with the CQC, NICE and others to ensure that providers have the evidence-based tools they need to make decisions to secure safe staffing levels. These decisions will then be subject to external scrutiny and challenge by commissioners, regulators and the public, and to inspection by the Chief Inspector of Hospitals.

However, at the end of the day we come back to the fundamental point, that it is the responsibility of individual providers to be accountable for staffing levels in their organisations. The existing registration requirements, which are enforced and monitored by the CQC, already recognise the importance of that. That is my response to Amendment 144. The requirements state that providers must take steps to ensure that at all times there are sufficient numbers of suitable staff to carry on the regulated activities that the organisation provides. Additionally, the Chief Inspector of Hospitals has also made it clear that appropriate staffing levels are part of the requirements of registration for the CQC.

In assessing whether a provider meets the registration requirement on staffing, the CQC refers to relevant guidance about staffing levels and skills mix published by professional councils and relevant expert and professional bodies. These include the Department of Health, Skills for Care, Skills for Health, the NHS and the Royal College of Nursing. Where a provider does not meet the staffing registration requirement, the CQC is able to use its enforcement powers to protect patients and service users from the risks of unsafe care associated with inadequate and/or poorly trained staff.

In its consultation document A New Start, published in June this year, the CQC stated that the focus of its new inspection methodology would be on five key domains. Are services safe, effective, caring, responsive to people’s needs, and well led? These domains will cut across all areas of activity, including levels of staffing and skill mix.

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The Government recognise the concerns expressed on previous occasions in your Lordships’ House about the training of this critical part of the workforce. However, I hope that the House will recognise our commitment to bringing greater consistency and quality to the training provided to healthcare assistants and social care support workers, enabling them to place compassionate care at the heart of everything they do. I beg to move.

[Lord Willis of Knaresborough]

My Lords, I rise, somewhat gobsmacked, as they say in Yorkshire, at the launching by my noble friend of what has been a major breakthrough in the training of healthcare support workers. I notice that the noble Baroness, Lady Gibson, is nodding in approval as this is an area with which she too has been very closely concerned. I thank my noble friend for making that commitment. It makes most of my speech totally irrelevant but, nevertheless, I will add one or two bits just for good measure.

There is no doubt that there is an overwhelming case for appropriately training the 1.3 million healthcare support workers who do such a fantastic job in care homes and domiciliary settings, as well as in hospitals. This has been a national scandal so far. These people are a hugely valuable part of the workforce and it is important to recognise them as such.

I should like to ask some brief questions. Camilla Cavendish recommended that the certificate of fundamental care be a baseline on which there would be an advanced certificate. That would lead directly into nurse training so that there would be no glass ceiling for healthcare support workers, particularly since nursing has moved on to being an all-graduate profession. When the Minister responds, I hope that he will be able to say whether that is within the psyche. The idea of having student nurses working alongside healthcare support workers, particularly those training for the advanced level, is a good one, so that you know the skills mix that you are working with.

In Amendment 153, I railed at the word “may”. The amendment states:

“Regulations made under this section by virtue of subsection (3)(d) may in particular include provision for a specified person”.

Surely, the Minister could go one step further and say that, at Third Reading, it will become a “must” and not a “may”. The one thing we must not have—there are a lot of musts—is a situation where people can move away from this need to be able to make sure that within a short period the whole of our social, health and care workforce will be properly trained to a standard approved by the sector skills council and the Nursing and Midwifery Council. That is a major breakthrough.

My noble friend is right that there are some excellent training programmes. I have seen many of them. I remember one for healthcare support workers at John Radcliffe Hospital in Oxford within the hospital setting. I know that many care homes give superb training to their staff because that leads to good patient outcomes which sell the product. Has any thought gone into existing training being recognised so that people do not have to go through another hoop for the sake of getting their certificate? Perhaps Health Education England can do that with this. I hope other noble Lords will comment on our amendment.

Amendment 160 remains a thorny issue. A mandatory regulatory system for healthcare support workers has been on the table. Francis himself made it clear that this workforce should be regulated. Until now, my problem with that has been that there has been very little to regulate because if people are not trained to approved standards, how on earth do you have a regulatory system by which you can judge their competence? Now that we are getting one, I hope that the Minister will look again at regulation so that we get the complete package and, my goodness, this will be a Care Bill that we can really celebrate.

[Lord Hunt of Kings Heath]

My Lords, the noble Lord, Lord Willis, has just referred to my Amendment 160. It relates to the regulation of health and care support workers. I have long thought that the regulation of support workers is necessary, desirable and inevitable because they play such an important role in caring for so many people. I pay tribute to the noble Lord, Lord Willis, for the outstanding work he did for the RCN’s independent commission which has informed this debate about standards of care workers.

I very much welcome what the Minister said about the development of a certificate of fundamental care. My noble friend Lord Young reminded me that I ought to ask the Minister at what level that is going to be because anyone who understands these issues will know that the level of a certificate is very important.

I want to draw together Amendments 153, 158 and 160. Given that in future when employers wish to take on care workers they will expect a certificate of fundamental care, does the Minister not think it inevitable that there will be a list of people who have been awarded the certificate? Does he not also think it inevitable that once you have that list, if you then have a person with a certificate and they transgress and there is concern about the way they care for people, there will inevitability be a drive to ask how you get that certificate off them? I believe regulation is inevitable now. There is no way away from the fact that once you have a certificate like this, there will have to be a list or a register and people will have to be evaluated. I for one very much welcome what the Minister has announced because it is a very important step along the road of regulation.

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[Earl Howe]

My Lords, at this point it will be convenient to consider also Amendments 166, 167 and 168. We have previously had some valuable debates about the Health Research Authority’s role in promoting transparency in research. I thank the Joint Committee that scrutinised the draft Bill and the Science and Technology Select Committee in the other place for their reports, which have informed Amendments 166 and 167.

In previous stages of the Bill’s passage, the noble Lords, Lord Patel, Lord Turnberg, Lord Warner and Lord Winston, the noble Baroness, Lady Wheeler, and my noble friend Lord Phillips of Sudbury have made particularly valuable contributions to the debate on this issue, which I have listened to with considerable interest. The Government have also discussed the Health Research Authority’s role in promoting transparency with stakeholders and with the existing special health authority.

The life sciences industry plays a key role in the Government’s strategy for economic growth and makes a valuable contribution to both the health and wealth of our nation. The Government agree that there is a powerful case for increasing transparency in clinical trials. Ensuring that research is registered and published and that data, information and tissue are available where relevant will help to make the best use of research, thereby maximising the health benefits for patients and the public from research undertaken and thus maximising the return on our investment in research. Amendment 166 makes it explicit that the Health Research Authority’s objective of facilitating the conduct of safe and ethical research includes promoting transparency in research. Amendment 167 lists some of the ways in which the HRA must promote transparency.

The existing special health authority is already making great strides in promoting transparency in research. The Health Research Authority published an action plan in May 2013, which received widespread support from a range of stakeholders including researchers, research sponsors, funders, professional bodies, stakeholders and members of the public with an interest in transparent research. Since 30 September, registration of clinical trials in a publicly accessible database has been a condition of favourable ethical approval from a research ethics committee.

These amendments will ensure that the Health Research Authority continues to promote greater transparency in research when it becomes a non-departmental public body. By doing so, that authority will continue to reassure people who participate in research that research is not duplicated unnecessarily and that unnecessary risks and burdens continue to be avoided. As promoting transparency in research is specifically included within its objective under Amendment 166, the Government would expect that the annual report would cover the authority’s measures to meet this section of its objective. While there is more to be done in this area, including by research funders, I hope that I have been able to reassure noble Lords that great strides are being taken and will continue to be taken.

Amendment 165 clarifies that the Health Research Authority may delegate any of its functions to any of its committees, sub-committees, members or any other person. The amendment mirrors a similar amendment that we have already debated with respect to Health Education England in Schedule 5—it was Amendment 157.

Finally, I would like to explain briefly Amendment 168, which corrects an oversight in the drafting of the Bill. It ensures that an appropriate body under the Mental Capacity Act (Appropriate Body) (England) Regulations 2006 is a research ethics committee recognised or established by or on behalf of the Health Research Authority, rather than a research ethics committee recognised by the Secretary of State.

I thank noble Lords and others for the contributions that have informed the amendments on the HRA’s role in promoting transparency in research. I hope that they will be welcomed. I beg to move.

[Lord Willis of Knaresborough]

My Lords, first, I declare an interest as the chair of the Association of Medical Research Charities. The brief comments that I am about to make are an amalgam of those made with the Academy of Medical Sciences, Cancer Research UK and the Wellcome Trust. On behalf of all those organisations, I can say how much we welcome these amendments and the way in which the HRA has so quickly become embedded into the research psyche. The work that it is doing ensures that on each of the major obstacles—of which ethics was the first, particularly in local ethics committees, but going right through to the regulation that it is starting to streamline, particularly with the Human Tissue Authority—we are really seeing a march forward. Frankly, the progress that has been made has staggered me. I congratulate not only the chairman and chief executive of that organisation but the Minister himself.

NHS: EU Legislation

Lord Willis of Knaresborough Excerpts

Monday 21st October 2013 Lords Chamber

[Earl Howe]

My Lords, I stress that this is not a step to find a way to make doctors work longer. As I said a moment ago, it is clearly in nobody’s interest to go back to the days when doctors were constantly tired and worked excessive hours. However, when senior clinicians tell us, as they have, that the implementation of the directive is harming patient safety and doctors’ training, we have to take that seriously. That is why we want to take a closer look at how this directive is impacting on the ground.

[Lord Willis of Knaresborough (LD)]

My Lords, I welcome my noble friend’s very strong comment that the working time directive has huge benefits, as well as clearly having challenges. However, in terms of this review of surgeons’ training, will he also look at the fact that for at least two and a half days a week most of our theatres are absolutely empty, with no activity taking place? One of the big requirements is that there should be more activity in terms of elective surgery within our hospitals—which would itself help the whole training issue.

[Earl Howe]

My noble friend makes an extremely good point, which I shall ensure is not lost on the president of the Royal College of Surgeons as he conducts his review.

Care Bill [HL]

Lord Willis of Knaresborough Excerpts

Wednesday 16th October 2013 Lords Chamber

[Lord Low of Dalston (CB)]

My Lords, I shall speak also to Amendments 138A and 138B, which are in my name in this group. I shall get those amendments out of the way first, as the debate is likely to focus principally on Amendment 83. Clause 75(6) says that anything done or not done by a third party authorised to carry out a particular function is treated as done or not done by the local authority. In effect, the local authority is solely responsible for the third party’s acts or omissions, subject to a couple of exceptions in subsection (7).

The Joint Committee on the draft Care and Support Bill recommended an amendment to make clear that a person with delegated authority is subject to the same legal obligations as the local authority itself. This reflected concerns that there should be a clear chain of accountability by which the individual could hold the third party, not just the local authority, responsible if their rights were infringed. The Government have contended that the clause already provides for continued accountability. They said that the local authority,

“will remain liable for the proper discharge of that function”.

This misconstrues what the Joint Committee was recommending. The Government are viewing accountability solely in terms of the relationship between the third party and the local authority. Subsection (6) precludes the possibility of the individual seeking redress from the third party, so it does not accord with the Joint Committee’s recommendation. The Minister in Committee said that care providers with delegated functions must carry them out in a way that complies with the Human Rights Act 1998 and that any failure to do so will be a failure by the local authority. That is not the same as the third party being subject to the Human Rights Act; the third party would be failing in its obligations to the local authority, but to no one else. The Minister effectively conceded as much when she said:

“By that device, the Human Rights Act would end up having an effect on what those third parties could do, even if they were not themselves directly responsible”.—[Official Report, 29/7/13; col. 1587.]

The noble Earl, in his letter to Peers following Committee stage, confirmed that individuals will have recourse only to third-party dispute resolution procedures or the local authority’s complaints process.

Without these amendments the individual will have no remedy against, for example, a private care home delivering poor service, or a private company failing to carry out proper assessments. We therefore need these amendments to give effect to the Joint Committee’s recommendation that a person with delegated authority should be subject to the same legal obligations as the local authority.

On Amendment 83, I set out the arguments in detail in Committee and shall not repeat them at length here. The matter is really quite simple and straightforward and can be stated briefly. The Human Rights Act 1998 applies to all public authorities and to other bodies when they are performing functions of a public nature. That means that it should apply to all providers of care, given that the provision of care is a public function. However, the matter was thrown into doubt in 2007 by the case of YL v Birmingham City Council, which held that care home services provided by private and third-sector organisations under a contract with the local authority did not come under the definition of “public function” for the purposes of the Human Rights Act. This meant that thousands of service users had no direct remedy against their care provider for abuse, neglect or undignified treatment. Though the public body commissioning the care remained bound by the Human Rights Act, that was of little practical value to the individual on the receiving end of poor or abusive treatment, or the person given four weeks’ notice to leave because they had antagonised their provider, about whom the noble Lord, Lord Warner, told us in Committee.

Accordingly, Section 145 was introduced into the Health and Social Care Act 2008 to clarify that residential care services provided or arranged by local authorities are covered by the Human Rights Act. There has been concern that this Bill would undo Section 145 by repealing Sections 21A and 26 of the National Assistance Act 1948, under which persons were placed in residential care and through which Section 145 has operated. However, the noble Baroness, Lady Northover, responding to the debate in Committee, set minds at rest on that when she provided the assurance that,

“there will be a consequential amendment to Section 145 of the Health and Social Care Act 2008 so that there will be no regression in human rights legislation”.—[Official Report, 22/7/13; col. 1118.]

However, there remains concern that Section 145 does not cover all care service users, or even all residential care service users. It only protects those placed in residential care under the National Assistance Act. That being so, it is anomalous not to treat residential care provided under other legislation and domiciliary care in the same way.

The noble Baroness, Lady Northover, reflecting the position put to the Joint Committee on the draft Care and Support Bill, further stated that the Government’s position is that all providers of publicly arranged health and social care services, including those in the private and voluntary sectors,

“should consider themselves to be bound by the duty imposed by section 6 of the Human Rights Act 1998 and not act in a way that is incompatible with a Convention right”.

However, there are two things wrong with this. First,

“should consider themselves to be bound”,

is not the same as “covered in law”. Secondly, the Joint Committee was not convinced. It concluded that, as a result of the decision in the YL case, statutory provision is required to ensure this. As I said in Committee, I have seen a letter in which it is stated that the Government’s position is that care providers are covered, and should not just “consider themselves to be bound”. However, the House of Lords in YL said that they were not and the Joint Committee was not convinced either. Given such uncertainty, it is surely essential that the matter is put beyond doubt in legislation and Amendment 83 would achieve this by deeming that all those providing social care services regulated by the CQC are exercising a public function for the purposes of Section 6 of the Human Rights Act.

The amendment would also include those who are eligible for care but who, due to means testing, have to arrange and/or pay for their own care—so-called “self funders”—and therefore currently lack the full protection of the Human Rights Act. To date, it has been the case, at least for those who were found to be eligible for care in their own home, that the obligation for the local authority to arrange care regardless of the person’s resources provided them with a degree of protection under the Human Rights Act. However, the changes to the system of arranging care to be introduced by the Bill weaken this protection. My amendment follows the approach of the Joint Committee and, if accepted, would provide equal protection to all users of regulated social care regardless of where that care is provided and who is paying for it.

The Government believe, as the Explanatory Notes to the draft Bill make clear, that protection under the Human Rights Act extends to care arranged by a local authority, even if it is self-funded, but the Joint Committee does not accept that this does not require explicit statutory provision. However, regardless of this view, it makes the point that it does not address the situation of self-funders, who arrange their own care and support. The Government, they say, will need to consider whether it is right that, of all adults in need of care, only this group should lack the protection of the Human Rights Act.

Given the manifold ambiguities and uncertainties surrounding this question, surely it is right to take this opportunity of putting the matter beyond doubt, as my amendment would do. What reason can the Government possibly have for resisting it, when all it does is to spell out in words of one syllable in the Bill that to which the Government have no objection—indeed, already believe to be the case—but which is subject to so much doubt in everybody else’s mind? I beg to move.

[Lord Willis of Knaresborough (LD)]

My Lords, I support Amendments 138A and 138B, but will not add to the excellent comments of the noble Lord, Lord Low. I speak in particular to Amendment 83.

I apologise to your Lordships for not having made any comments in Committee but, as I have pointed out, I was away from the House on the orders of my wife. In supporting Amendment 83, I acknowledge the excellent supporting brief from the Equality and Human Rights Commission. In particular, I thank my noble friend Lord Lester of Herne Hill, who sadly cannot be here today, for his considerable guidance.

The amendment stems from a failure by successive Governments to heed the recommendations of the Joint Committee on Human Rights and the Joint Committee on the draft Care and Support Bill to legislate to tackle the problem created by the majority decision of the Law Lords in 2007 in the case of YL v Birmingham City Council.

In YL, the issue was whether a care home, such as that run by Southern Cross Healthcare Ltd, was performing functions of a public nature for the purposes of the Human Rights Act when providing accommodation and care to a resident such as Mrs YL under arrangements made by Southern Cross with Birmingham City Council under Sections 21 and 26 of the National Assistance Act 1948.

The Law Lords decided by three votes to two—the noble and learned Lord, Lord Bingham, and the noble and learned Baroness, Lady Hale, dissenting—that they were not performing a function of a public nature. However, anyone reading the dissenting judgments of the noble and learned Lord and the noble and learned Baroness would understand why the majority ruling appeared contrary to the objective and purpose of the Human Rights Act. The previous Government thought that YL was wrongly decided and I assume that the present Government share that view. It would be useful if the Minister could confirm that that is the Government’s position.

The previous Government then sought to resolve the problem by intervening in test litigation to clarify or overturn YL, but that did not prove possible. The JCHR twice recommended remedial action, but the previous Government refused to take such action or to support the efforts of Andrew Dismore MP, as the chair of the JCHR, to do so by means of a Private Member’s Bill.

[Lord Wills (Lab)]

I am very grateful to the noble Lord for giving way and I hesitate to interrupt him, because I agree with almost everything that he is saying, but on a factual point he is wrong. The previous Government—and I was the responsible Minister—did not disagree. We were trying to find a way of resolving this and we ran out of time. It is not that we disagree with it; we were wholly in agreement with the efforts made by Andrew Dismore. We were simply trying to find a robust way of dealing with that particular problem and we ran out of time.

[Lord Willis of Knaresborough]

I thank my former honorary opponent for that clarification and I certainly would not wish to contradict him. The reality is that the previous Government did, in fact, try to find a way out of this judgment and to correct it in a way which they thought would be beneficial for the people of England and Wales. Instead, they introduced an amendment to the Health and Social Care Act 2008 to extend human rights protection to those receiving residential care arranged by a public authority. The amendment did not extend, as the noble Lord, Lord Low, rightly said, to home care services, even though they were provided under a similar statutory framework. It is that gap that this amendment is designed to fill. Surely there is precious little difference between a local authority securing care services of an individual in a residential care setting or in someone’s own home. That is the kernel of this particular problem.

The Department of Health has explained the Government’s position in Written Answers to the JCHR. It said that,

“all providers of publicly arranged health and social care services, including private and voluntary sector providers, should consider themselves to be bound by the duty imposed by section 6 of the Human Rights Act 1998, and not to act in a way which is incompatible with a convention right”.—[Official Report, Commons, 17/7/12; col. 702W.]

We are told that:

“The case law supports a broad application of Section 6(3)(b) and provides that individual factors should be considered in each case. As such YL was a case on the particular facts, and it does not necessarily follow that the reasoning in that case will be applied to other social care settings”.

I find that very difficult to understand. Can the Minister explain the department’s judgment in that way?

The factual settings in YL in favour of a finding that Southern Cross was indeed performing a function of a public nature could not have been stronger, and yet were rejected by the majority so that legislative intervention became necessary. The department says that all providers should consider themselves bound by a Section 6 duty, but the law is entirely uncertain as it stands whether they are required by law to do so.

The department continues in its letter to JCHR:

“The Government do not therefore consider that an amendment to the Human Rights Act 1998 is necessary.”

But Amendment 83 is not seeking to amend the general test in Section 6 of the HRA, but to make it clear that someone who provides regulated social care is to be taken for the purpose of Section 6 (3)(b) to be exercising functions of a public nature in doing so. It is hard to see how it could be otherwise. The department continues by saying that the government position remains that:

“Any amendment to the Human Rights Act in relation to third sector and private providers … risks casting doubt about the interpretation of the Human Rights Act”.

However, the uncertainty is created not by this amendment but by the decision in YL, and by the fact that the amendment made by the previous Parliament was too narrow.

The Joint Select Committee on the draft Bill, chaired by Paul Burstow MP, included strong membership from all sides of the House. The committee’s report, published on 19 March, considered the Government’s arguments with great care at paragraphs 280 to 292, and concluded that the present amendment is absolutely necessary.

I therefore hope that the Minister will have had discussions with his ministerial colleagues and officials and will be able to accept the amendment in the name of the noble Lord, Lord Low, without the need to test the opinion of the House.

[Lord Hope of Craighead (CB)]

My Lords, I will say a few words in support of Amendment 83 in the name of the noble Lord, Lord Low. Before I say anything I will follow the example of the noble Lord, Lord Willis, and apologise for not having taken part in proceedings on this Bill before. As the Minister may know, I have recently returned from a period of disqualification, which has now been lifted on my retirement from the UK Supreme Court, so I am now able to speak, which I was not able to before. I thought I might contribute just a few thoughts to this debate against the background of that experience.

My first point is that Section 6(3)(b) of the Human Rights Act is one of the few provisions in what was an excellently drafted Act which, in my experience, judges have found rather difficult to apply in practice. The reasons for this were explained by the noble and learned Lord, Lord Neuberger, in YL. He made the point that any reasoned decision about the meaning of that phrase,

“functions of a public nature”,

risked falling foul of—as he put it—circularity, preconception and arbitrariness. The words are quite imprecise, so one has to search for some kind of policy guidance as an aid to their interpretation. There may be a whole variety of factors in one case taken with another that have to be brought into account as one tries to reach an answer—and in practice, answers are quite hard to predict.

With great respect to the noble Lord, Lord Willis, it is not helpful to ask at this stage whether YL was wrongly decided; we have to take the decision as we find it. That is how the law works. Of course, it is always open to Parliament to take a different view and judges—and, I am certain, noble Lords in that case—appreciate that entirely, as the noble Lord, Lord Neuberger, did for a reason I will come to in a moment. We have to assume that the judges in the lower courts will follow the decision in YL if other cases come before them, and it may not be all that easy for the Supreme Court—if the issue comes back before it in some future case—to depart from the basic reasoning in YL. I therefore suggest that one has simply to approach these issues on the basis that YL is there, and proceed accordingly.

The solution to the problem which the noble Lord, Lord Neuberger, indicated in his speech, at the very end of quite a long judgment, was that if the legislature considered it appropriate that residents in privately owned care homes should be given convention rights protection against the proprietors, it would be right for the legislature to spell that out in terms and make it clear that the rights should be enjoyed by all such residents. The words “spell it out”, which I think the noble Lord, Lord Willis, used, make the point that one has to have something which puts the matter plainly on the record and which gets over the difficulty created by the very broad reach of the subsection in Section 6.

As we have heard—I do not need to go over the ground again myself—an amendment was made to the 2008 Act which did not extend to regulated home care services, so there is a gap. There are, therefore, two questions. First, should the gap be filled? Secondly, which is a question for the Minister, how should that be done?

As far as the first point is concerned, as I understand the progress of events, and my reading has indicated this, there is not really any dispute about this because the Department of Health’s position, as explained to the Joint Committee on Human Rights, is that,

“all providers of publicly arranged health and social care services … should consider themselves to be bound by the duty imposed by section 6 … not to act in a way which is incompatible with a convention right”.—[Official Report, Commons, 17/7/12; col. WA 702.]

I think it was also suggested that it would not necessarily follow that the decision in YL, which was about a care home, would apply to other social care solutions.

I see a difficulty with that approach. Comments of the kind that were made, that people should consider themselves bound by a convention right, however well intentioned, do not have the force of law. They could not be relied upon, for example, in a court to guide a judge about the meaning of Section 6(3)(b) in the particular context. Therefore, they leave the law in a state of uncertainty because they do not have the force of law, and they have no relevance to a decision that the court would have to take.

If one takes the example of a provider who is faced with a claim from a person who is in need of care and not receiving it or whose rights are being infringed, that provider will probably have to seek legal advice as to what should be done. Legal advice would take the provider back to YL, and we find ourselves once again faced with the gap to which other speakers have drawn attention. It is perfectly true that YL was a decision on its own facts, but I respectfully suggest that the implications of the decision go wider than that. If you read the judgments, there is a distinction between private, profit-making bodies on the one hand and state or government-owned bodies with public functions on the other. One can debate how far private and profit-making bodies may be caught by the section, but that is the area which is creating difficulty.

The fact that that body was regulated, which was the situation in YL, was not determinative. The fact that we are dealing with social care which is regulated is not the answer to the problem. That is where the gap now confronts us. I would respectfully suggest, in support of the amendment of the noble Lord, Lord Low, that the answer is to do as the noble and learned Lord, Lord Neuberger, urged us to do at the end of his judgment and to spell it out in terms that a person who provides regulated social care is to be taken to be exercising a public function.

There is another point. A failure by Parliament to grasp this opportunity now and to make it clear will be noticed. There is a risk that, if that opportunity is not taken by Parliament now, courts may take this as a sign that Parliament is content with the law as it stands and may be understood to be on the basis of YL.

I absolutely appreciate that there is a question for the Minister whether this amendment would have wider implications. From my own experience, and having read the judgment in YL too, I am quite certain that thought passed through the minds of the judges. There is reference, for example, to schools and other institutions; the judges may have considered, “If we make a pronouncement about this, it may affect other circumstances and situations”. There is a difference, of course, between a judge making that kind of pronouncement and Parliament’s putting forward or putting into a measure a precisely targeted measure which deals with a particular problem. It is the difference between a sledgehammer, I would say, to crack a nut, and a rapier which deals with a particular issue. I do not see that there is any real risk that, by dealing with the matter in the targeted way that the amendment of the noble Lord, Lord Low, seeks to do, it will be taken as a signal in the courts that there is some wider reach in Section 6(3)(b) from that which was being discussed in YL.

It is a difficult issue, but I respectfully suggest that it has to be addressed now and that there is a real risk that, if we do not do it now, it will give rise to real problems later. I warmly support the initiative of the noble Lord, Lord Low.

NHS: Out-of-Hours Services

Lord Willis of Knaresborough Excerpts

Monday 29th July 2013 Lords Chamber

[Earl Howe]

I apologise to the noble Baroness on two counts. NHS Direct is a separate, statutory organisation, which means that the management and controls of risk are the responsibility of the NHS Direct board.

[Lord Willis of Knaresborough]

My Lords, may I try to redress the balance? There is a real sense that very significant numbers of people calling the 111 service get a good service. On 9 June, I had reason to call 111 because I was having a heart attack. The response from 111 was excellent, in York. At the same time not only did the service call the paramedics but it had me in hospital within 25 minutes to an absolutely superb accident and emergency service. If York can do that in such an efficient and superb way, why cannot we guarantee that service throughout the country?

[Earl Howe]

I am sure that I speak for all of us in saying how pleased I am that the service worked so well in the noble Lord’s case. The answer to his broader question is that the service is working well in the vast bulk of the country. Unfortunately, in two particular areas we have seen problems, which are being gripped, and I am confident that NHS England has taken these issues forward with the seriousness that they deserve. I am assured that, even in the areas where problems have arisen, the service is good.

Care Bill [HL]

Lord Willis of Knaresborough Excerpts

Tuesday 4th June 2013 Lords Chamber

[Lord Willis of Knaresborough]

My Lords, I support Amendment 12 in particular. I declare an interest as an honorary fellow of the Royal College of Nursing.

When I was preparing the Commission on Nursing Education report, although we were looking at pre-registration, one of the key elements that came up time and again was that nurses were leaving their training and going into settings, within NHS tertiary care settings, primary care settings and, in particular, community settings and domiciliary settings, where the notion of continuing professional development was non-existent. People were finding an immediate barrier to even asking questions about doing things in a better way. The way you overcome that is by doing exactly what it says in this amendment. You put at the very heart of your organisation the fact that you continue to develop. Even preceptorship, the year after training, was given scant regard in many places because the nurses were so busy doing their day-to-day tasks that there was not time for management to put it in. My argument is that without putting in that training, you are less efficient, you give poorer care and ultimately the whole organisation suffers. I hope that my honourable friend will take on board this crucial business about ensuring that Health Education England is not just about training at the base level, but is about continuing to train people throughout the whole of their professional lives.

[Baroness Emerton]

My Lords, I will add to what the noble Lord, Lord Willis, said. A lot of work is being done on the appraisal system, but without the appraisal system leading into continuing professional development, professional development becomes ad hoc. A lot of work is being done by the noble Baroness, Lady Cumberlege on appraisal, and I believe that some work is being done by the department as well. If we could link this work with continuing professional development, I think that that would be very helpful.

--- Later in debate ---

[Lord Willis of Knaresborough]

I speak to Amendments 15 and 36 in my name and those of the noble Baroness, Lady Emerton, and the noble Lord, Lord Patel. On Amendment 15, one of the most daunting tasks for Sir Keith Pearson and his staff at Health Education England is the challenge of workforce planning. I do not believe that anybody has done that right in the health service since its creation. The noble Lord, Lord Turnberg, rightly pointed out that it takes a good five years to get a junior doctor. It takes 10 years to get a consultant. For senior consultants, we are probably talking about 12 to 15 years. For anyone to sit down in Richmond House or elsewhere and start to plan what is going to happen in 10 to 15 years is an incredibly difficult task, and no one has managed it yet.

Secondly, looking ahead, if 10 or 15 years ago you were planning a workforce, you would have automatically said that we need a supply of certain groups of professionals and that, provided we can get that supply, we will be reasonably okay. We can bring in a few from abroad, usually the Commonwealth, and often denude the poorest countries in Africa of their health staff and get the nurses from the Philippines. That enabled us to get by.

What we are doing now—I think that the Minister is acutely aware of this— is planning for a health and care service the like of which we have never seen. There will be research developments, especially in areas such as genomics and regenerative medicine, which will create cures for major debilitating diseases and, at the same time, give us innovative ways of dealing with people’s long-term chronic illness in their homes by self-management. Therefore, the professionals and the care support workers for those professionals working within the NHS have to be of a calibre and to have a flexibility the like of which we have never seen.

We have tabled Amendment 15 because HEE needs all the support that it can get in obtaining representation to support it to look ahead. By that, I am talking about the research base. We have to consider what medicine will look like, what cures will look like and what the demographic requirements will be in 10 or 15 years’ time—or even in five years—to plan the workforce. I hope that in reply, the Minister can reassure the House that there is that sort of long-term planning for a workforce not like today’s. We are not planning the workforce of yesterday with different numbers, we are looking at a totally different workforce for the future.

Amendment 36 is a probing amendment to gain assurances from the Minister that HEE will receive representations from organisations other than the medical royal colleges. The Explanatory Notes to the Bill specify only medical royal colleges in paragraph 515. We therefore ask that that be updated to reflect all royal colleges.

In the Francis report, one of the criticisms of the Royal College of Nursing—I refer to it specifically—was that there was a conflict between its role as a trade union and its role as a royal college. The Government and Health Education England have an opportunity to challenge it on that role and to make sure that it steps up to the mark as a royal college. Only by doing that will it actually serve the nursing workforce to its true extent. We have seen that with the medical royal colleges, and, by including royal colleges in this particular amendment, which would include the Royal College of Nursing, we are sending out a challenge to the RCN that it, too, must be part of this game rather than a bystander.

[Baroness Wall of New Barnet]

My Lords, I, too, support Amendment 36. I just want to pick out something that the noble Earl mentioned a little while ago in response to another question from me. He mentioned the work being done by Skills for Health and Skills for Care. Certainly in the context of this amendment—which, I agree, is a probing amendment—alongside the royal colleges and the other professional bodies, the work that Skills for Health and Skills for Care are doing is hugely important. Can the noble Earl enlighten me on what relationship Health Education England will have with those bodies? For instance, the noble Lord just referred to what the future looks like and what Skills for Health in particular is doing alongside Skills for Care. It is looking at what provisions there are for apprenticeships inside the health service, which is hugely important and allows people to develop from smaller roles to bigger roles over time. I wonder how, in the scheme of things, that relationship exists, how close it is and what influence Skills for Health and Skills for Care have, so that they are not working in opposition but are working integrally with what HEE is doing.

--- Later in debate ---

[Earl Howe]

I am grateful to the noble Baroness. I have to go a little further, so if I may I will cover her point in a moment.

Amendments 40 and 42 to 46, tabled by the noble Lord, Lord Hunt, and the noble Baroness Lady Wheeler, focus on the need for expertise on the local education and training board. Specifically they seek to change Clause 91(3) to require a LETB also to have as members persons who deliver education and training to healthcare workers, a registered nurse, persons with experience in staff groups that are not professionally registered, healthcare workers who receive education and training from within the area, patients and carers or their representatives, and a representative of the local health and well-being board.

I fully expect Health Education England and the LETBs to work closely with and seek advice from a range of key stakeholders, including those providing education and training, members of staff, patients and carers. That requirement is clearly set out in Clause 89. I appreciate the position of noble Lords but do not agree that we need to specify all these groups in the governance structure.

In establishing the LETBs, the Government are committed to driving up standards and the quality of education and training provided. I suggest that that can happen only if those directly involved in the provision of education and training are at the heart of the new system. By their very nature, local education and training boards will be representative of local healthcare providers, who play a critical role in educating and training our workforce. They are the health professionals who support and supervise clinical placements and training programmes across the country, providing professional leadership and support to students and trainees.

If we mandate a requirement for a nurse, others will ask why there is no requirement for a doctor, a dentist, an allied health professional or any of the many other professions. I completely agree that these professions, and the bodies that represent, regulate and support them, need to be closely engaged in the work of the LETBs, but it is not practical to require all of them to be members of the board. The Bill makes provision in Clause 91 for those involved in the provision of education and training, such as universities, to be eligible to sit on an LETB. We know from the 13 LETBs established by the HEE special health authority that all of them have a university representative on their boards, and many different health professionals are also represented on them.

HEE will appoint independent chairs of the LETBs. These will be people who are not directly involved in the delivery of health services, or education and training, in the geographical area. Having an independent chair will ensure that the local education and training board acts independently and in the interests of all healthcare providers represented.

To be appointed in the first place, local education and training boards will need to demonstrate to HEE that they have the right governance arrangements and the right mix of people on their boards with the necessary capacity and capability. In going through that process it will be for HEE to assess whether the local education and training board has the right mix of skills, knowledge and expertise with which to carry out its functions. However, as the intention is for local decisions on education and training to be made by the LETBs, it is important that we give them the flexibility to determine who sits on their boards.

To sum up the position, I can reassure noble Lords that LETBs are already developing strong partnership arrangements in their patch to engage with all education institutions involved in education provision in their area. The HEE special health authority has reinforced the importance of this in the appointment criteria that it set the LETBs, which have to be approved by the Secretary of State. These demand that LETBs demonstrate meaningful engagement and collaboration with many stakeholders with an interest in education and training, including students and trainees, and patients and carers. As a result, they are putting in place appropriate advisory and partnership arrangements to support the decision-making of the local education and training board.

[Lord Willis of Knaresborough]

Perhaps I may interrupt the Minister and come back to the important point made by the noble Baroness, Lady Wall. In responding the Minister has yet again constantly referred to what I would call professional organisations. There are nearly 1 million healthcare support workers in the care and the health sectors. Many are untrained. Most are unregulated and unregistered. The two organisations that are providing basic skills, Skills for Health and Skills for Care, were dreamt up within the department. They did not widely consult before they put their forward their proposals for training programmes. The Nursing and Midwifery Council was never asked about the standards for Skills for Health. Will the Minister say who will be consulted about training the people who do so much of our basic social and healthcare—those who are called healthcare support workers?

[Earl Howe]

I fully recognise the importance of the healthcare support worker sector. I can reassure my noble friend and the noble Baroness, Lady Wall, that Health Education England will be working closely with the sector skills councils, Skills for Health and Skills for Care. I note my noble friend’s scepticism about those bodies, but I do not share it. They have done a pretty fine piece of work and the fruits of it will be apparent over the coming months. HEE will need to do that if it is to perform its role as fully as it should to plan and shape the development of the entire workforce. If by some mischance it were to neglect that aspect of its work and not focus on improving training standards for the health and care support workforce, it would lead to a very unbalanced and unsatisfactory position. Therefore, we are very clear that this should be part of the remit of Health Education England. I hope that that is sufficient reassurance for noble Lords.

The noble Lord, Lord Hunt, asked about health and well-being boards being represented on LETBs. There is a clear commitment in Clause 93 for LETBs to consult health and well-being boards in the development of their plans.

My noble friend Lord Willis asked how Health Education England’s workforce planning will take into account new innovations. Workforce planning is a key focus for Health Education England. It is not about churning out the same old numbers but about working with service commissioners, service providers and other partners such as royal colleges to understand how the workforce needs to respond to service change. This means taking account of technological, pharmaceutical and other advances, and having a flexible workforce that is able to adapt to those innovations.

--- Later in debate ---

[Baroness Emerton]

Amendment 19, on the importance of practical-based training in the education of clinicians, follows on from what the noble Baroness, Lady Wall, and the noble Lord, Lord Hunt, have just said. Because we are moving so quickly in healthcare delivery and the integration and multi-professional working, perhaps we should be looking at how holistic care, which is what I think is being referred to—the ability to see the patient pathway from primary care through to hospital care and back out to primary care—can be a pathway that nurses in particular are trained to be able to execute and to ensure that the transition from one to the other is smooth and without hiccups.

The complaint that we are getting at the moment from the public is that there is a complete block in some areas where the staff are just not aware of what the discharge policies should be and what is at the other end. That picks up the point raised by the noble Lord, Lord Hunt, about the practical skills and the need to look at the curricula from the academic area and put them back into the practice area.

Amendment 14 concerns HEE’s staffing and skills mix in carrying out its functions. When we look at the skills mix, what we are really looking for is an evidence base. We want to look not at static numbers but at evidence based on the safety level. If the minimum is based on the safety level, we are looking at something that can be a useful guide on which to base our working.

[Lord Willis of Knaresborough]

My Lords, I shall speak to Amendments 26 and 33. Like the noble Baroness, Lady Emerton, I also emphasise the importance of Amendment 19. While it is a rather small amendment, it has huge significance.

Talking to people from Health Education England recently, I was struck by the desire in the Francis report about the whole issue of practical training. When a significant amount of the training of medics, doctors and nurses is carried out in practical situations, one asks how you can get the sort of situations that the noble Lord, Lord Hunt, referred to. When nurses spend 50% of their time in practical situations, how do they come out of their training not ready to be deployed in certain areas? To be fair, when you see the time and the effort that is put into mentoring in many of these settings and the quality of that mentoring, you start to realise that there is a big problem. I hope that on Report we can bring back some of the issues relating to mentoring, or at least get some satisfaction from the Minister that this issue will be taken incredibly seriously in health education. If it is not, we will continue to have people who in theory are trained well but in practical terms are really not as fit for purpose as they should be. That will not be their fault; it will be our fault.

Amendment 26 very much echoes the thoughts behind Amendment 27. I particularly welcome in Amendment 27 the idea of having a 10-year plan. In fact, five years is short-term. It is better than what we have at the moment, but a 10-year plan is a really good idea, and I am sorry that I did not table that amendment. I saw it but thought that we would not want two amendments along the same lines.

On Amendment 26, Clause 85(1) of the Care Bill defines Health Education England’s responsibility as ensuring that,

“a sufficient number of persons with the skills and training to work as health care workers for the purposes of the health service is available to do so throughout England”.

Who could disagree with that? What a noble suggestion. While that would clearly include both healthcare support workers and nurses, the mandate, which was helpfully provided by the Minister before this debate, sets out a strategic national role in relation to medicine, dentistry and pharmacy in paragraph 5.2.6, and proposes a five-year workforce plan for “smaller specialties and professions” in paragraph 5.2.7, but provides little information on how the nursing workforce or the healthcare support workforce is to be undertaken and implemented. Does that not tell us all we need to know about what the priorities still are? While we have good words within the Bill, we do not have anything within the mandate that backs them up in a real sense. Midwives and health visitors suddenly appear, but I think that the commitment to having a comprehensive workforce under a five-year plan is worth really striving for.

Amendment 33 looks at the future guidance and standards for safe levels of staffing. I have a real problem with allocating numbers. When I was in another place, I remember arguing with the then Government about class sizes for years 1 and 2 in primary schools, where there had to be 30 children or fewer and the 31st child had to go somewhere else. You realise that, depending on the setting, you can do all sorts of different things. What we must not do is tie down the hands of high-quality management in being able to deploy staff in the most appropriate way. What matters is getting the mix of staff absolutely right. I hope that we will return to the question of staffing levels because it is fundamental but, frankly, we could go down the wrong road if we took it too seriously.

[Lord Touhig]

My Lords, time and again in this House the matter of training of health professionals so that they better understand how to support and care for people with autism has been debated. Here, I should declare an interest as a vice-president of the National Autistic Society. We know that key professionals such as GPs and community care assessors still do not have a good enough understanding of autism.

Amendment 24, about which the noble Lord, Lord Rix, has spoken and to which I have added my name in support, if taken on board by the Government would at least ensure that the Secretary of State would be required to consult vulnerable people, including those with autism, their carers and groups such as the National Autistic Society, Mencap and others on matters affecting education and training that will be provided by Health Education England.

Only one in three adults with autism in this country told the National Autistic Society in a survey that in their experience social workers have a good understanding of autism. There is a well established correlation between the professionals’ understanding of autism and the degree of identification of needs among adults in that local authority area with the condition. Autism training can help ensure that adults with autism are correctly identified, and qualify for the support they need.

I recently served on the autism and aging commission, chaired by the noble Baroness, Lady Greengross. Professor Francesca Happé gave evidence about the difficulties of picking up on autistic people’s needs. She said:

“This is a group that doesn’t self-present, doesn’t come and seek services, because of their difficulties of social interaction and communication and we absolutely owe it to them to go and find out what their needs are”.

For that reason, we need well trained people to support them.

The National Autistic Society’s excellent document, Push for Action: We Need to Turn the Autism Act into Action, made a very good case. It includes a very good case study by the mother of an adult with autism. Her name is Chloe, and she says:

“We got to the point where Peter couldn’t live at home, for his own and our safety. After moving around between people he knew and staying in a B&B, eventually he got a flat but he still doesn’t get any support. Social services don’t understand autism and how it affects him. They’re not asking the right questions. They say, ‘How are you?’, and he says, ‘I’m fine’, so they come back to me and say, ‘He’s fine, he doesn’t need any help’. But of course he says he’s fine at that point because he probably is at that point”.

He does not trust them, so he says he is fine in order to make them go away because he does not believe that they understand or are able to help him.

“He had a mental capacity assessment and they asked him about managing his money. He told them that he was saving money for a motorbike but he doesn’t have any money. He can’t manage his money. He gets into all sorts of trouble”.

Chloe concludes:

“I’ve given up asking for support. Me and my husband now do everything ourselves … Now we have no expectations of what ‘services’ should be providing”.

That is just one example of the lack of trained staff having an adverse impact on the life of an autistic person and their family.

I hope the Government will ensure that autism training is included in the core curricula for doctors, nurses and other clinicians, in accordance with the commitments under the Adult Autism Strategy. It is absolutely necessary that vulnerable groups, including people with autism, are consulted about priorities for training so that decision-makers become aware of the gaps in knowledge and understanding among health professionals.

Ultimately, the Government must tackle the issue by including autism training in the core curricula for doctors, nurses and other clinicians, as they committed to do in the 2010 Adult Autism Strategy. People with a learning disability and/or autism have the right to the same quality of healthcare as those without. I believe that Amendment 24 is a good step forward in achieving that.

Care Bill [HL]

Lord Willis of Knaresborough Excerpts

Tuesday 4th June 2013 Lords Chamber

[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.

[Baroness Emerton]

My Lords, I support the noble Lords, Lord Hunt, Lord Turnberg and Lord Willis, in their recommendation that a registered nurse should be on the board.

An issue that Francis picked up after the report is that the nursing voices are not strong. He said he was disappointed in the response from the nurses. We now have to ensure that the nurses on the board are equipped with the knowledge and expertise to be able to speak out and hold their own. The training of senior nurses in standing at the board table and making their voices heard and understood on quality, safety and the patient experience is going to be very important. Therefore, it links very much with the leadership training, which we also need to address, in terms of their preparation. Perhaps the noble Earl will comment on that.

--- Later in debate ---

[Earl Howe]

It will certainly be open to the board of HEE to establish an advisory committee that specialises in unregulated professions. Although, again, I cannot make a firm commitment about that, the very fact that we are dealing with a workforce of substantial size on which the NHS crucially depends—I am now talking about healthcare support workers—means that it would be very surprising indeed if the board were not to have some form of specialist advisory service to inform its decisions.

[Lord Willis of Knaresborough]

Before we finish debating this group of amendments, will my noble friend reflect on what he has just said about regulation? One of the traps we fell into with the Health and Social Care Bill—I do not think that it was intentional, it just happened—was that so much was promised in regulation that it was not until we started discussing the regulations that we saw what we had not done in the Bill. Perhaps it would be helpful to produce draft regulations as we go along before Report, so that we know what we are including in the regulations.

[Earl Howe]

It may not surprise my noble friend to know that I asked my officials the self-same question, because I anticipated an appetite for draft regulations. I am, unfortunately, not in a position to make that promise, much as I would like to do so, because there may not be the necessary time available for the regulations to be drawn up in draft. However, I will take back the strength of my noble friend’s request and see whether there can be any reconsideration of that point.

Care Bill [HL]

Lord Willis of Knaresborough Excerpts

Tuesday 21st May 2013 Lords Chamber

[Lord Willis of Knaresborough]

My Lords, what a privilege it is to follow the noble Baroness, Lady Bakewell. If there is to be a commissioner for the old in England, I second her nomination at this point.

I also congratulate the Government on bringing together these timely reforms to our social care system. When the noble Baroness, Lady Bakewell, was talking about the problems for local government, I was reminded that it is 20 years since I was elected to North Yorkshire County Council for the first time and put in charge of looking after the budget for adult social services. It was an impossible task 20 years ago. It is an impossible task today. Her remarks are very timely in concentrating our efforts on getting that right.

Parts 1 and 2 begin to address key questions of affordability and access addressed by the Dilnot commission and the issues of quality and safeguarding highlighted by the Francis report. Although modernising the legal framework, as proposed by the Law Commission, and clarifying the rights of individuals and their carers, is an important step, no one should suggest that the Bill will rectify decades of neglect in our social care system. Here, I agree very strongly with my noble and learned friend Lord Mackay that not until we have completely aligned our health and social care systems can many of the issues recognised by Dilnot be fully addressed. Nor would anybody suggest that the proposed new funding arrangements will be a panacea, but they provide at least a more equitable solution than exists at present and afford the nation a breathing space until a more radical solution can be found. I say “more radical” because the reality is that at the current rate of increased demand our health and social care system is not sustainable.

About 30% of the UK population currently suffers from a chronic disease, many with co-morbidities, and the rates of increase are frightening, as are the costs. Seven and a half million of us are being treated for hypertension—many I suspect in this Chamber at the moment—which is up 11% since 2006-07; 2.5 million are treated for diabetes, which is up 25%; 1.8 million have chronic kidney disease, which is up 45% since 2007; 800,000 have long-term cancers, which is up 79% since 2007; and 270,000 have long-term dementia, which is a rise of 25% over that six-year period.

Unless we seek better ways of preventing the onset of chronic conditions and managing them more effectively in the community, or even better finding cures, many of the worthy reforms in this Bill will merely provide respite care. This is why I am so supportive of Part 3, the setting up of Health Education England and the Health Research Authority as arm’s-length bodies. The way we will transform the health and care landscapes radically is by improving the education and training of the workforce, and by giving it the tools to transform patient care by using our outstanding research base.

Health Education England has already made a hugely positive start under the excellent leadership of Sir Keith Pearson, but the need to move swiftly to NDPB status to make sure that we align workforce planning with education and training is essential. What is missing from the legislation is a duty to future proof workforce supply into the NHS and social care system. There should not be a three-year plan for LETBs but a 10-year rolling target so that we avoid the feast and famine often associated with kneejerk reactions from government Ministers as problems of nurse, doctor and consultant shortages appear.

We cannot allow a return to local, short-term self-interest that is the real danger for the LETBs; nor must we exclude the private and voluntary sectors, the key role that they must play in workforce planning, and—crucially—the contribution that they must make to training and education. When he replies I hope the Minister will say how the private and voluntary sectors will be brought in. Incidentally, I am delighted that in Clause 82 there is now a duty for Health Education England to promote research. I congratulate the draft Bill committee for getting that into the Bill, but why does this duty not extend to the LETBs? Improvements will come about only if all the workforce recognises the value of research and puts it at the heart of its daily routines. LETBs are crucial to this agenda. Perhaps the Minister can explain why they have been excluded from that duty.

There are many other issues that need to be raised over Health Education England, but one requires an urgent response. The damning criticism in the Francis report about the role of healthcare workers is largely ignored in this legislation, as are crucial elements concerning nurse education. Francis was clear about the need to train, regulate and register HCAs. These recommendations were also strongly made by the recent commission that I chaired, but in the Bill there is no regulation and no registration, and only a minimalist training programme that is not mandatory.

Can I suggest to the Minister that at the earliest possible date Skills for Health is quietly retired, that new standards are set by the NMC and that Health Education England is mandated to ensure high-quality training with appropriate certification for all healthcare support workers? I understand the challenges of adopting a fully fledged registration scheme, but ensuring that any healthcare support worker who cares directly for patients is trained to a mandatory standard, and that training is certificated and registered for inspection with employers, is surely achievable. Making employers legally responsible for registering the competency of their staff and regularly updating that competency safeguards patients, staff and the reputation of the provider.

Finally, I am delighted with the progress made on the HRA so far. The HRA has demonstrated that it is more than an enhanced national ethics service, which I feared it might become, and I congratulate the Minister and his colleagues on ensuring that it was given that freedom. The crucial next step of creating an NDPB with scope to make the NHS and our social care system the most research-intensive in the world is hugely exciting. However, there remains timidity about the legislation in this Bill. In 2011, the Academy of Medical Sciences highlighted the need for better and more streamlined regulation, and we are not there yet. Clause 93 gives the HRA the duty to promote the co-ordination and standardisation of practice in the UK with regard to health and social care research, but will this extend to the removal of unnecessary levels of regulation?

At a recent Science and Technology Select Committee hearing, part of its inquiry into regenerative medicine, one regulator said to the members, who included the noble Lord, Lord Winston, that because the science was complicated, so must the regulation be. That is what bedevils the regulatory framework for research. The power of different regulators to gold-plate their regulation continues to worry me. Does the HFEA really have a role in embryonic stem cell research, or could its regulatory functions be subsumed by the HRA or indeed be merged with the Human Tissue Authority? Will the HRA have the powers to abolish, or at least to recommend to Parliament the abolition of, unnecessary regulators, or will those regulators, with their independence, still have the upper hand?

As we move to more stratified medicines, regenerative medicine and greater emphasis on genomics and bioinformatics, the key will be to move fast with often small groups or lone patients. The current system of regulation is too burdensome and cumbersome for us to be able to act. The system is simply not fit for purpose. Surely we should be seeking to strengthen the powers of the HRA so that it can decide appropriate regulatory pathways, rather than the existing regulators.

A similar issue arises with National Health Service research and development permissions. The HRA has done brilliantly in streamlining local ethics approvals, but there are still difficulties with individual trusts over site approvals. Not only does each site have to give approval, but if there are variations to a clinical trial, the whole process has to be repeated. This is nonsense if we are aiming for more trials involving more patients at more sites. Simply publishing good guidance, as expected in Clause 98, is insufficient. I hope the Minister will go further and say how the HRA will ensure that trusts have regard to its guidance. Of course, the success of research and the HRA will depend significantly on public buy-in, an issue which the Joint Committee took very seriously. Transparency is key, and the open publication of data should be a statutory requirement for the HRA. The Association of Medical Research Charities, which I chair, has just published Our Vision for Research in the NHS, which includes, from all members of the charity, a call to publish research results and make them accessible.

This is an excellent Bill. It has huge potential. It is not a panacea. It is a great start, but it needs a little bit of courage, and I urge the Minister to have that courage.

NHS: Mid Staffordshire NHS Foundation Trust

Lord Willis of Knaresborough Excerpts

Monday 11th March 2013 Lords Chamber

[Lord Willis of Knaresborough]

My Lords, I, too, thank the noble Lord, Lord Patel, for introducing this debate and for the measured way in which he did so. It behoves us not to begin a blame game but rather to pick up the recommendations of this superb report and act upon them. It is far more profitable. A few of us who were sat in another place during the time that this was going on raised the sorts of concerns that are now being raised with hindsight.

In the time available, I should like to concentrate on recommendations 185 to 213, which affect nursing and healthcare support workers. What concerns me about this report—and indeed these recommendations—is how we can prioritise and implement them, because trying to prioritise and implement 290 at the same time is, quite frankly, an impossible task. As was said by the noble Viscount, Lord Eccles, time has not stood still since Mid Staffs. The Nursing and Midwifery Council has produced new standards for pre-registration nursing training, which are widely welcomed by patient groups, by the higher education institutions, by professionals and by providers.

As we move to a fully graduate nursing profession, I trust we will not waste time re-opening the issue of a graduate nurse workforce, as indicated by Ann Clwyd in another place. Francis quite rightly recommends a greater emphasis on recruiting caring as well as intelligent students, but believing these two qualities to be mutually exclusive is disingenuous. With less than 25% of current nurses being graduates, it was not graduate training that caused a lack of care at Mid Staffs. The quality of the placements where nurses receive their practical training requires urgent attention, as does the quality of mentorship they receive.

The 50% practical placement is fundamental to the development of a well trained workforce, yet far too often students are dissatisfied with the quality of the experience they receive on their placements. Fewer placements are now in hospital settings, particularly acute hospital settings, and staff are often too busy to give of their time. Learning is not seen as a corporate activity and, more worryingly, core competencies are sometimes neither practised or observed before being signed off. At the core of this problem is the outdated view that all registered nurses can be good mentors, and that somehow mentorship can be added to very busy schedules with little training or additional time. That must change. If we want our nurses to be inspired to be more patient-centred, then the practical learning settings must be of the highest possible standard. Mentors must care for their students, and be valued by their employers.

Francis also recognised that throughout our health and care system more and more care is delivered by untrained and unregulated healthcare assistants. Regulation 209 is perhaps the most powerful statement made by Francis, stating that,

“no unregistered person should be permitted to provide for reward direct physical care to patients currently under the care and treatment of a registered nurse or a registered doctor”.

We do not in fact allow anyone to work on a gas fire without proper training, yet we allow people to work on those who are in the greatest need.

The first step—I hope the Minister would agree—is to have mandatory training by the end of this Parliament, with standards for all healthcare support workers who provide direct physical care approved by the NMC, or another body which the Secretary of State approves. Without mandatory training, it will be unlawful for employers to engage these workers. To the Minister, who is worried about registration, I suggest that an immediate step toward independent registration would be that by the end of this Parliament every employer who provides direct physical care will be required to keep a register of all their employees who deliver care. Their training records should be available for inspection by the CQC, Monitor and Healthwatch England, or its regional equivalents. Surely patients and their families have the right to know at least that those who care for them are at least appropriately trained, and that their employers will be held responsible for their deployment.