Health and Social Care Bill

My Lords, I rise to speak to Amendment 240, tabled in my name, which relates to the mandatory training and statutory regulation of healthcare support workers. Before so doing, I thank the noble Earl, Lord Howe, and the noble Baroness, Lady Northover, for the time that they have given me in addressing this issue and for their very helpful responses. The Bill is concerned with reorganising health service structures to improve the quality and safety of care and to improve the patient experience, building on the work of the noble Lord, Lord Darzi, in the last Government. The emphasis throughout the Bill is the role to be taken in the commissioning of services by general practitioners, but little attention has been paid to the other professions. Here I declare my interests as a retired nurse not on the Nursing and Midwifery Council register, a former tutor, manager and chair of the regulatory body for nurses, midwives and health visitors. I am also a lay member of the GMC, a former chairman of an NHS trust and a former trustee of the Kent Community Housing Trust. I remind the House that nursing and midwifery form the largest individual professions in the NHS, currently with in excess of 600,000 names on the register. Moreover, some 400,000 members of the Royal College of Nursing support this amendment. It is concerned with the safe delivery of care to patients whether they are in hospital, in the community or within the NHS, local authority or independent sectors, along with nursing homes and charities. I am grateful to all noble Lords who took part in the debates in Committee on the two amendments that I tabled then, the first of which asked the Government to produce guidelines on the ratios of registered to unregistered staff. I withdrew that amendment on the basis that further work would take place examining the research evidence. I am pleased to say that Ministers have taken this seriously and work is now in hand on the matter. I mention this as the ratio of nurses to unregistered staff is important in the points to which I now wish to draw the attention of noble Lords in making the case for healthcare support workers to be regulated against agreed standards and for this to be included in the Bill. If this amendment is accepted, it would affect healthcare support workers—those who are limited to working under the direction of a registered nurse or midwife giving direct clinical care in hospitals, community settings and care homes. They would have accepted professional boundaries and would be entitled to practise, as set out on a list. There would be control of admission to and removal from the register. Professional standards of practice would be established, ensuring clarity for patients, the public and professionals, and individuals would be held accountable. In a letter to me, the noble Earl said that the department is ““unconvinced”” that the regulation of support workers is necessary and that the Government's policy is to set up a voluntary register. I am hoping to convince the Minister that having healthcare support workers subject to a voluntary register would not work satisfactorily in terms of protecting patients in the delivery of safe care. I pose two brief questions. First, what is the evidence to demonstrate that unsafe care is currently being delivered by healthcare support workers and the reasons for this? Secondly, is there evidence that will satisfy patients, the public and registered practitioners that the proposed voluntary register will ensure the safe delivery of care? While a very large number of healthcare support workers deliver excellent care, most of them having received some basic training under adequate supervision and having gained experience, there is evidence that things can and do go dreadfully wrong, particularly where there is no appropriate training and poor supervision. Healthcare support workers are themselves calling for mandatory training and regulation. We have only to refer to the most recent inquiries demonstrating unsatisfactory levels of care in Mid Staffordshire NHS Foundation Trust. The first report was very critical of healthcare support workers and the change in the staffing ratio of registered nurses to support workers. The second public inquiry is reporting on the confusion about supervision—not knowing who was in charge of care delivery. At Winterbourne View, a hospital delivering care to those with learning difficulties, charges were brought against support workers and guilty pleas have been made. The report published by the Local Government Ombudsman cited 10 instances of unacceptable care for the elderly. Moreover, prior to this there were inquiries at Maidstone and Tunbridge Wells NHS Trust and at Stoke Mandeville Hospital. While the failures in delivery of care were not due solely to the poor performance of healthcare support workers, that was found to be very largely a contributory cause. Failure in delivery of safe service care was due in the main to there being insufficient registered nurses to supervise the healthcare support workers and a lack of a set of standards for care training. A survey of 2,500 support workers carried out by the Royal College of Nursing between the Committee and Report stages of this Bill demonstrated that tasks currently being undertaken by healthcare support workers call into question the safety of patient care. The list totals 56 examples, but I will illustrate just a few. Healthcare support workers were left in charge of wards and nursing homes, administration of drugs, including insulin and controlled drugs, the removal of wound drains and central lines, bladder scanning and washouts, catheterisations, especially in very ill patients, assessing patients pre-operatively and pre-chemotherapy treatment, changing tracheotomy tubes, inserting nasogastric tubes, giving feeds through those tubes, and suturing and plastering. These are just a few. As recently as last Friday, I was chairing a national conference and was approached by a very senior nurse who told me of a family member, a young person of 17, who had applied for a job as a healthcare support worker. She received two days' training. On the first day on the ward, she was allocated to do a bed bath. She was accompanied by another healthcare support worker to supervise her. She washed the patient's face and hands and proceeded to complete the bath, but was told by the other healthcare assistant, ““I only do hands and face here. We don't bother to do anything else””. When questioned about the patient's back and pressure areas, she was again told, ““We do not do that here””. Very many of our workers are in that situation, both in the community and in hospitals. A House of Commons Health Select Committee report says about the future of regulation: "““The Committee endorses mandatory statutory regulation of healthcare assistants and support workers and we believe that this is the only approach which maximises public protection. The Committee notes that the Government intends to give powers to the relevant regulators to establish voluntary registers for non-regulated professionals and workers, but would urge it to see healthcare assistants, support workers and assistant practitioners as exceptions to this approach who should be subject to mandatory statutory regulation. However, the NMC””—" that is, the Nursing and Midwifery Council— "““needs to make significant improvements in the conduct of its existing core functions (such as in how it manages fitness to practise cases) before powers to register these groups are handed to it””." This is now work in progress. It is not possible to provide evidence that a voluntary register would be satisfactory, but I can show why a voluntary register for healthcare support workers would not solve the problems that I have illustrated. A healthcare support worker works under the direction of a registered nurse or midwife, who delegates the task having judged the competency, knowledge and experience of that support worker. The list of tasks currently being undertaken is such that it is doubtful that adequate training has been given, and most fall outwith the tasks that a support worker should be expected to carry out. As already stated, there is not yet a set of standards which would form an agreed list of tasks that healthcare support workers could work to. The Government have asked Skills for Health and Skills for Care to carry out this work. Are registered practitioners and university lecturers involved in this programme of development? I ask this question because I know that the former chief executive of the Nursing and Midwifery Council was asked by the Minister and the Department of Health to become a board member of Skills for Health and Skills for Care and to make the appropriate contributions for the regulating body. There is a need for his professional input in the interests of safety of patient care, not just courses teaching skills without the appropriate level of knowledge to accompany those skills—that is, the ability to recognise a change that indicates that further help is needed. I gave in Committee the example of the taking of blood pressure and the consequences of not knowing what a change in the reading might mean. There is considerable scepticism over the possible introduction of a voluntary register for this group of workers, mainly because those who most need to register are the least likely to do so, especially with so many unemployed people taking any possible job on offer without proper scrutiny. A voluntary register provides no mechanism to stop people working—that is, a fitness-to-practise investigation. Plurality of employers and greater employee mobility could present problems for a voluntary register. It would be difficult to check where people moved to and to keep tabs on their whereabouts. There would be no single register and no single point of contact. There is already confusion for public and patients, and a voluntary register would add to that. There needs to be consistency. There are no current enforceable standards—I accept that preparations are being made to ensure that standards are set. Anyone could set up a voluntary register. Some could be kitemarked and some not. There are issues around how a voluntary register would work alongside the Independent Safeguarding Authority. Would it be fit for purpose in determining fitness to practise if presented with a person considered unfit for work? Surely healthcare support workers deserve more than this. They are often subject to misuse and abuse. But we are where we are. Registered nurses are frequently placed in an impossible position because the numbers available in relation to the number of support workers to be supervised under their delegation make it difficult to ensure that safe practice is being delivered. That is especially so now with the cuts in registered nurses and midwives in the current economic situation and the Nicholson challenge of the £20 billion savings target. Patients and the public need to be assured that they are the recipients of safe care delivered by appropriately qualified staff. The confusion that currently exists about who is who in the team causes anxiety to patients and relatives. Patients and relatives know when a doctor comes to see them that he or she is qualified and registered with the GMC to do the job. At the present time, they cannot be sure whether they are being treated by a registered nurse or a healthcare support worker unless the demarcation is easily identifiable to a patient, member of the family or the public. The situation that we are faced with is a very serious one and urgent action needs to be taken. There is no short-cut remedy. What is needed is an ordered strategy that takes evidence on the requirements of safety, high-quality care and good patient experience in hospital, the community or the care home, providing holistic care and at the same time cost-effective results. The work that is being examined on the evidence relating to the proportion of registered nurses to support workers shows that care must take the lead. The professions of nursing and midwifery must be allowed to take a lead and assist in determining and demonstrating their worth as professionals, to regain the confidence of patients, the public and the Government, and in turn to determine the level of support workers that they need to deliver this high-quality, holistic care. That can be done by involving the recently created Nursing and Care Quality Forum, created by the Prime Minister, involving the Royal College of Nursing, the Royal College of Midwives and other professional bodies and unions. Of course there are two new chief nursing sisters—one to be appointed this week to the national Commissioning Board and one already appointed as Chief Nursing Officer of public health—who will help to lead in this. I have set out why I do not think that a voluntary register is an answer. I am looking for a commitment that the mandatory training for healthcare support workers will have a strong input from the profession in developing and validating the competencies and outcomes required for healthcare support workers. I also want a commitment to review that education and training to establish the benefits that it has had for patient safety. I beg to move.