NHS Care of Older People

Paul Burstow Excerpts

Thursday 27th October 2011 Westminster Hall

[The Minister of State, Department of Health (Paul Burstow)]

I start by thanking the Backbench Business Committee for scheduling the debate and the hon. Member for Stourbridge (Margot James) for securing it. We have heard personal testimonies and powerful speeches today. There have been thoughtful contributions and I want to make sure that the debate is seen by colleagues at the CQC. The relevant national clinical directors, the chief nursing officer and the chief executive of the NHS ought to read the report of the debate because it encapsulates in a very powerful way the challenges, as well as the opportunities to move on and make a difference for the people we are here to serve.

I want to address the problem and then describe some of the things that are happening and discuss what more needs to happen. Whether in the NHS or in our wider care and support system, poor quality care can never be acceptable and should find no hiding-place in our country. Many hon. Members have rightly expressed their serious concerns that such shocking and neglectful care can be—or appear to be—tolerated within our NHS, and that kindness and compassion can go missing on some wards. The hon. Member for Bolton West (Julie Hilling) described her journey and the way the system almost seems to have imprisoned people with good intentions and disempowered them. The point about empowering staff to live their values in their practice is an incredibly important one.

I will not speak to the social care piece of the debate in great detail today. The Backbench Business Committee has scheduled a debate on social care on 10 November, and I look forward to that broader debate. I will talk about the problem that we have been wrestling with today. Sadly, it is not a new issue. The ombudsman report, “Care and Compassion”, is just one in a long line. Evidence of poor or variable care for older people can be found in major clinical audits on continence care or falls and bone health undertaken by the Royal College of Physicians; in the work of NCEPOD—the national confidential enquiry into patient outcome and death—and its inquiry into pre-operative care for the over-80s, chillingly titled “an age old problem”; in the findings from the national hip fracture database; in the parliamentary inquiry into the human rights of older people in health and social care; in the many reports by charities such as Age UK and the Alzheimer’s Society on acute care and nutrition; or in the Mid Staffs inquiry. Taken together, those reports, audits and inquiries, which go back years not months, paint a disturbing picture that quite rightly has been rehearsed here today. They demand action.

Some people try to reduce the issues to problems that need simplistic solutions, of which there are none. Some people see the issue as an opportunity to make criticisms of modern nursing or the role of health care assistants, which misses the point of so many of the reports I just listed. Such issues do not have a single cause, so there cannot be a single magic bullet solution. However, I am clear that we have to move on from merely describing the problem. There is an almost constant cycle of revisiting the problem, but never actually solving it. We need to identify steps to solve it.

I shall outline some of the steps the Government are taking in concert with others—it cannot just be governmental action—to stamp out poor care and to embed a culture of quality care, and zero tolerance of behaviours and systems that do not facilitate that care. I cannot cover all the actions that are taking place; only some. The level of non-compliance uncovered by the CQC inspections in 100 hospitals was inexcusable; in my view, there are no mitigating circumstances that can relieve medical staff of the duty they owe their patients. I agree with the hon. Member for Leicester West (Liz Kendall), who said that follow-ups by the CQC need to be rapid and proportionate. Matters cannot be left unanswered. Once concerns have been identified, they need to be properly followed up to ensure they are addressed.

My hon. Friends the Members for Suffolk Coastal (Dr Coffey) and for Waveney (Peter Aldous) mentioned the James Paget hospital. I shall not usurp the role of the CQC, but its report has made it clear that the trust could face prosecution or suspension of services for the failures that have been identified. We must now await the next report, and expect speedy and timely action from the CQC as it discharges its responsibilities.

As part of the next wave of inspections announced yesterday by the Secretary of State, the CQC will carry out inspections not only on a nine-to-five, Monday to Friday basis, but outside normal hours so that we get the fullest possible picture. That is essential and it is right for that point to be raised. The CQC will undertake 500 inspections, also outside normal hours, to look at residential care for elderly people. It will look at the care and welfare of service users and their nutritional needs, which will shine an important light on issues of dignity and care in the sector. The CQC will not only highlight care homes that are not performing well; it will put those that are as they should be into the spotlight to take the applause they deserve when they get it right.

Let me put the debate into context. There is nothing inevitable about illness and disability in old age. Dementia or falling over are not normal parts of ageing; illness and ageing are not synonymous, and we must get that point across when designing our systems. That does not mean that an ageing population poses no challenges to our health care system because it does, but it is also a cause for celebration. The age shift taking place in our society is one of the biggest challenges we face, and it is right that Parliament should spend more time debating it.

Caring for older people is the everyday business of the NHS and a core part of what it does. People over 65 account for 65% of hospital admissions and 70% of bed days. We must, therefore, look carefully, critically and constructively at how the model of care needs to adapt to address those needs. We have an episodic model but we need one that reflects co-morbidities, complexity and long-term conditions. That is the challenge, and it requires the debate that we shall have on social care, which is the other side of the same coin.

The hon. Member for Nottingham South (Lilian Greenwood) referred to dementia. We estimate that a quarter of people in every adult acute hospital suffer from dementia or confusion that is often undiagnosed and too often ignored. That failure to diagnose can add days to the length of a person’s stay in hospital, and create additional distress for the patient and their family. The hon. Member for Waveney spoke of a sense of déjà-vu, which I feel that I have shared for many years. In opposition, I repeatedly raised the issues under discussion and argued that at their root lie ageist assumptions and practices. Time and time again, I pressed for a systematic approach to ageism in the NHS, and for the law to state beyond doubt that ageism is unacceptable; one of my first acts as a Minister was to rule out any exemptions from the age discrimination duty for the NHS. In future, the arbitrary use of age cannot be used in the NHS as a means of limiting the care and treatment that older people receive.

The introduction of the equality delivery system across the NHS, involving leadership at all levels, means that for the first time a mechanism is in place to challenge and change the culture and behaviours that allow ageism to prosper. I greatly welcome the initiative led by the NHS Confederation, the Local Government Association and Age UK to look at issues of dignity, and the Department is working closely with them on that. We expect, however, that the work will look beyond analysing problems; we have done too much of that and there are too many reports sitting on shelves. The problem has been analysed but we now need practical steps to deliver change.

A debate such as this must go beyond discussing the problems; we must highlight the stories that are told less often. In many places, care is exceptional and excellent, and 45 of the hospitals inspected were fully compliant with the essential standards. Many NHS trusts take care seriously and want to get it right for older people. At University Hospital Southampton NHS Trust, for example, the Southampton meal-time assistance study is evaluating the effectiveness of additional help from volunteers at meal times on acute medical wards for older people. University Hospitals Birmingham NHS Trust is implementing a systematic trust-wide approach to improve dignity, which includes using the stories of carers and patients—the story related by the hon. Member for Bolton West would be relevant—in its clinical governance arrangements and regular dignity rounds. The Department has funded work by the Royal College of Nursing on improving dementia care in general hospitals. That initiative was launched in September, and the RCN spelt out its commitment to the care of people with dementia and noted the critical factors essential to delivering good quality care.

There is, therefore, no shortage of tools, guidance, ideas or initiatives that can be taken to tackle these issues. If we get safe and dignified care right for older people, we will get it right for the majority of those who use our health service. It is not always about money but about attitude, approach and doing things differently. Often, it can be something simple such as putting ourselves in the patient’s position and looking at the service through their eyes. At Sheffield’s Northern General hospital, for example, patients and carers were concerned because they could not tell the difference between different types of staff on the ward, so staff put up colourful and simple posters around the hospital that identified them by the colour of their clothing. That suddenly lifted a barrier to patients’ understanding of what was going on around them, and made a real difference.

Several hon. Members have mentioned staffing levels, which is an important matter. The CQC expects registered organisations to ensure that they have enough skilled and trained staff to deliver the care expected of them, and failure to comply carries all the relevant enforcement powers and consequences. The RCN has published guidance on staffing ratios, and we expect that to be consulted and used by nurse leaders, who should have the freedom to agree staff profiles for their organisations. We all recognise, however, that it is not an exact science, which returns us to the quality of leadership and culture, which many hon. Members mentioned.

The role of nurses and health care assistants has been mentioned by several hon. Members. At the heart of good nursing lie values of compassion, respect for the rights of the individual, empathy and kindness. The principles of nursing practice are clear and the Government believe that nurses must be recruited for their values, trained for their skills and empowered to practise their values in their work. That means that universities and NHS organisations must work together on the selection of students to ensure that requirements for education and practice are met, not least because the pace of technological and pharmacological change demands higher levels of knowledge and skills to deliver high-quality patient care. Having a degree-educated work force does not mean placing technical competence ahead of values; that is a key point in ensuring that caring does not turn into the specialist service that some hon. Members fear it is becoming.

Caring demands high standards, leadership, and a readiness to challenge poor practice and demonstrate good practice. I will follow up the suggestion about meeting the Nursing and Midwifery Council, and I will ask my officials to discuss the matter with the Minister responsible for nursing, my hon. Friend the Member for Guildford (Anne Milton), who I know takes a close interest in such issues.

The role of health care assistants has been raised, and it is worth noting that the Government have put into legislation for the first time the power to regulate health care assistants. We are breaking new ground, although I am sure some will feel that we are not doing so quickly enough. We are taking a measured approach, however, by legislating for the Council for Healthcare Regulatory Excellence to establish a voluntary registration scheme that will set a benchmark for training, conduct and competence. However, it is our view that it is right to place responsibility fully and squarely on employers to decide whether to select staff on the basis of their registration. They must ensure that staff have received the necessary training for the role that they are undertaking.

The hon. Member for Wirral South (Alison McGovern) made a very important point, which I encapsulate in this way. We have an NHS that all too often can be described in industrial process terms. We need an NHS that is all about personalisation and that is personalised to the individual. That is an important part of the transformation that we need.

Leadership has rightly been talked about a lot in the debate. It is critical. Directors of nursing, medical directors and other health professionals must deal with the issues raised in the CQC report. Just as the CQC has turned a spotlight on dignity and nutrition, so too must every NHS trust look at the report and take a long hard look at itself and the stories that this debate has highlighted. Too often after things have gone wrong, we learn time and time again—sadly, the debate has underlined that point—about the staff who tried to alert senior clinical colleagues or managers only to be ignored or, even worse, victimised, or about the patients and families who have been on the sharp end of appalling care and who are marginalised, with their experience not being used to challenge and change poor practice.

We all have such cases in our mailbags. We have all had constituents in our surgeries who feel let down because they have not been listened to and who do not feel that there has been any learning as a consequence of their experience. There can be no place in the NHS where staff feel unable to speak up when patients are being put at risk, and no place in the NHS where the voice of patients and carers is not heard loud and clear.

When the hon. Member for Worsley and Eccles South (Barbara Keeley) talked about complaints handling, she made very important points. Getting redress or an apology should not be a battle. People should not have to feel that the lessons are not being learned. It must be staff on the front line who work on the wards every day and see poor care—patients not being fed properly, privacy neglected, poor continence care or, as the hon. Lady said, pain relief overlooked—who change things for the better. That is why we are placing all providers under a duty of candour and why we are strengthening the NHS constitution to put beyond doubt the duty on managers to support staff who raise concerns about the quality of care. That point was touched on in the debate. We need to send a clear message that managers must support staff who raise concerns about the quality of care. It is also why we are establishing HealthWatch England and local HealthWatch to champion the interests of patients and carers.

There can be and should be no hiding place for poor care. The CQC inspections that the Government ordered are part of the work to take that agenda forward, but are by no means all of it. There is no magic bullet solution to this problem. We need a wide range of things: an effective inspection and regulation regime, which measures what matters to patients and carers and then takes action; guidance on what good practice looks like—for instance, the range of National Institute for Health and Clinical Excellence quality standards and guidelines on older people’s care; and the systematic involvement of older people and carers in the design of services from the outset.

We need greater transparency on complaints. We must ensure that we get it right the first time and that we value complaints as a way of learning and changing the way organisations and leaders in organisations behave. Feedback is needed to improve services. People must seek continuously to improve services. Another element is use of the law. We sometimes debate human rights in a very negative way. In this area, human rights are central, and we must deliver them for older people. We must use our equalities duty legislation as well.

Another requirement is effective advocacy and leadership from professions at every level—at ward level, at institution level and at the level of the Royal Colleges and specialist societies. We need a work force supported with the training and skills to make them fit to care for an ageing population. That is a new challenge, and we need to adapt to meet it. Other requirements are advocacy and support from the voluntary sector and—notwithstanding some of our debates about system change—system incentives, such as outcome indicators and best practice tariffs to drive the right behaviours. We need much more transparency around performance data, such as those provided by CQC inspections, audits and satisfaction surveys. We need a greater focus on integration—many hon. Members touched on this—so that older people are in hospital only when they need to be. Hospital is not the right place for most older people in most circumstances.

This is about culture and systems. The Government recognise that. We know that we cannot do it on our own. We are working with others to make the changes that are needed. Yes, there has to be action now. The Government are taking immediate action by casting the spotlight where it needs to be. We must then sustain the action to get the transformation that is essential to delivering quality of care and the dignity and rights of older people in the NHS and anywhere else they need care.