Health and Social Care Bill

My Lords, I shall speak to this amendment in my name on the power to regulate healthcare support workers, which is supported by the Royal College of Nursing. I begin by declaring an interest: I am a retired nurse, nurse tutor and manager; former chair of the nursing, midwifery and health visiting regulating body, the UKCC; and past chair of an NHS trust. I start by looking back to the Bill’s beginning and its aim to improve the quality of patient care at every level of the NHS and to integrate social care, providing holistic care with clearly defined care pathways. The three constituents, as we know, to improving care are improving clinical outcomes, the safety of the patient and a good patient experience. The current situation is that, almost daily, a report is made of essential care being below an acceptable standard, or of poor hygiene, poor hydration, poor nutrition and poor personal care, with staff not even washing patients, making them comfortable or listening to their immediate anxieties. Where healthcare support workers move into areas of work beyond their competence, questions have to be asked about the safety of patients. For example, if a healthcare support worker is left to give drugs without supervision, this is an unsafe practice and a danger to the patient. The responsible person is the registered nurse, who is accountable for delegating any area of practice to the healthcare support worker. However, the growth in numbers of healthcare support workers dates back a long way and those numbers continue to rise. Over time, there has been a variation of titles, roles and functions, and there have been calls for regulation by the Royal College of Nursing since 1999, when Project 2000 was introduced and the enrolled nurse training was phased out. The reason given for phasing out this training, and the case for change in moving nursing to higher education, was that the rapid developments in medicine and technology led to a need for registered nurses to have a more detailed knowledge to equip them to be fit to the level of practice required—that is, to have a degree qualification. Holistic care of patients demands a correlation of knowledge and practical application that meets the total physical, mental and spiritual needs of patients, their relatives and friends. Degree courses contain 50 per cent theory and 50 per cent supervised practice. Enrolled nurses had played a very important part in the delivery of care, but they were being abused and misused by being placed in charge of acute wards at night, and taking on roles that their training had not equipped them for. We face the same situation today, where healthcare support workers are abused and misused by being expected to take on roles they have not been prepared for, and are left unsupervised. This raises three important issues. First, there is the role of the registered nurse, who dedicates and supervises the healthcare support worker. The problem is that if there are not enough registered nurses to supervise, then they become unsupervised. We know from the recent inquiry into Mid Staffs that in order to change the finance situation there, the ratio of registered nurses to untrained nurses was reversed from 60 per cent trained to 40 per cent untrained, to 40 per cent trained and 60 per cent untrained, leaving the registered nurse with a much larger task in supervision. The role parameters within which the healthcare support worker works, and the preparation they have had, needs to be looked at. Who sets the code of conduct—the employer, or the profession of nursing, midwifery and social care? Recent inquiries into failing healthcare systems have pointed to a range of causes, from trust boards and their executive and non-executive members, to the bedside and the delivery of care—that is, registered nurses and unregistered healthcare support workers. The most recent inquiry was at Mid Staffordshire, which I have already mentioned. Not only was an inquiry held to identify the failings; there was a further inquiry, on the demand of the public, to discover the root causes. Events this year at Winterbourne View, a unit for those with learning disabilities, resulted in a number of healthcare support workers being arrested, and a registered nurse went before the NMC for a hearing on fitness to practise. Inquiries in the 1960s at Ely, Farleigh, Whittingham, Normansfield, and more recently at Stoke Mandeville and Maidstone and Tunbridge Wells trusts, all demonstrated failing systems of care delivery, the involvement of all levels of care staff, and an overall lack of leadership from the board to the bed in maintaining delivery of high-quality care. How can Her Majesty’s Government allow the NHS to continue a system that has been proven to fail? The public and patients deserve—and have the right to expect—high quality and safe delivery of care. The Royal College of Nursing has been pressing the Government since 1999 to address this issue, and it continues to do so, recognising the complexity of the issue and that there have been some attempts to rectify an unsatisfactory situation. The chairman of the Royal College of Nursing healthcare support workers group sat in on the debate on front-line nursing on 1 December in this Chamber, and pleaded with me afterwards to ensure that regulation of support workers would be taken on by Her Majesty’s Government. The way in which the assistant nursing practitioner level 4 healthcare support worker has been introduced under Agenda for Change has identified and clearly set out the role parameters within which a healthcare support worker can work under the supervision of a registered practitioner, having reached a recognised but not regulated standard. However, this accounts for only a small number of the total healthcare support workers employed in the hospital and community setting. Further work could easily lead to mandatory training and registration by opening the second part of the Nursing and Midwifery Council register for this clearly identified group. That has been suggested in this House several times. The Secretary of State, the right honourable Andrew Lansley, recently announced that Skills for Health and Skills for Care have been commissioned to develop a programme of training and code of conduct to set the standards and training for healthcare support workers. They are also to produce a voluntary register, not regulation. I welcome that the Government recognise that there is a problem which requires urgent addressing, but there are several factors that would need to be addressed if this proposal is to solve the problem. A skill can be taught, but the deliverer of that skill will not necessarily have the background knowledge needed to take appropriate action. For example, only a few weeks ago a consultant who was visiting a patient asked the person who was taking and charting the blood pressure if she had been doing so all day. The answer was yes. The consultant then asked what the chart showed. She answered that the blood pressure was going down. Asked what that meant, she replied, ““I don’t know. I’ve only been shown how to take blood pressure””. Asked if she had reported this to the registered nurse, she replied no. Asked if she had been asked to report any changes, she replied no. The consultant then explained that falling blood pressure in this particular patient indicated that her condition was deteriorating almost to the point of death. This illustrates that a skill without background knowledge is of no use in the delivery of high-quality care, and that supervision of this healthcare support worker by a registered nurse was missing. There are many more examples that could demonstrate this point. Patients know that when they are approached by a doctor, he is a practitioner registered by the General Medical Council. Even if he is a junior doctor, he is accountable for his actions. However, there is no clarity as to whether the person carrying out a patient’s treatment is necessarily a registered nurse or a healthcare support worker. The colour of the uniforms is confusing, and healthcare support workers are often mistaken for registered nurses. Patients need to know by whom they are being treated. I welcome the invitation extended to the Nursing and Midwifery Council’s excellent chief executive officer, Professor Dickon Weir-Hughes, to participate in Skills for Health. He can bring to the table the statutory functions of the regulatory body, its responsibility towards fitness to practise of registrants and its leadership role. This is a complex set of issues, but it is vital to the safety of patients. I refer to the research evidence on the ratios of trained to untrained staff that I gave in a debate on Amendment 138 on 29 November in Committee, and to a further reference in a debate on front-line nursing two days later. It demonstrates that the higher the ratio of registered practitioners to non-registered healthcare support workers, the higher the quality of holistic care, resulting in good clinical outcomes, quicker discharge and fewer readmissions with good patient experience. This in turn leads to lowered mortality and morbidity rates, and as a result a possible reduction in hospital beds. This should be taken into account. I am most appreciative of the Minister for undertaking in his summing-up of that front-line nursing debate to take away the research findings for further study. The complexity of this whole situation, created by the proposed integration of health and social care in the Bill with more patients being cared for in the community, calls for urgent action to ensure that within the community setting there are sufficient registered nurses to maintain high-quality holistic care. The recent report of the Queen’s Nursing Institute contains figures showing that much needs to be done to raise the number of district nurses. The current work being undertaken to increase the number of health visitors and the Royal College of Midwives’ recent report on the number of midwives also have to be taken into account. Working as a registered nurse in the community is very different from working as a registered nurse in the acute sector. Special training is required for working in patients’ homes, and is currently insufficient to take the huge influx of elderly, frail patients from hospital. I suggest that this requires an in-depth study of the workforce and training requirements, with a cost-benefit analysis, taking into account research evidence from this country, by Professor Anne Marie Rafferty, and from the USA, Canada and Australia. Meanwhile, during the course of the in-depth study, remedial action should continue to be taken to ensure that the healthcare support workers programme is in preparation. I would like to suggest that the issues surrounding the problems of integrating health and social care could be assisted by introducing a core programme as an induction to health and social care for healthcare support workers, followed by a branch for nursing and one for social care. This will not only equip healthcare support workers in the day-to-day delivery of care, but lead to a better understanding of the different cultures of NHS and social care working, both in the community and in secondary care, already discussed earlier this morning. I find the proposal of a voluntary register totally unacceptable, unless it becomes a requirement for the employer to ensure that the employment of a healthcare support worker requires the evidence of satisfactory completion of the course, subject to the code of conduct. However, there would be nothing to prevent a healthcare support worker dismissed from his post going to another part of the country and being employed without having to go through a fitness-to-practise procedure. It has to be appreciated that the NHS is not the sole employer of healthcare support workers. In fact, a higher proportion is employed in the independent sector, nursing homes and residential homes, where the safety of patients and residents is just as important. It would also be important to ensure that there is an opportunity for the development of healthcare support workers, so that they can progress in one of the health and social care professions. I hope that I have set out the complexity of this situation, and I would ask the Minister to respond to the amendment, which the Royal College of Nursing vigorously supports, and to look at the regulation of healthcare support workers. I beg to move.