Health and Social Care Bill

My Lords, this has been a good debate and I, too, congratulate the noble Baroness, Lady Emerton, on her initiative in bringing forward her amendment. I should remind the House that I chair an NHS foundation trust and, like my noble friend Lady Wall, we employ many hundreds of healthcare support workers. I agree with everything my noble friend said. The noble Baroness, Lady Howarth, raised an important point. We are coming on to the issue of social care regulation and the House will know that I am very concerned about the transfer of social care regulation to what is essentially a health body. The noble Baroness, Lady Emerton, will want to respond, but it seems to me that what she has tried to do is to allow the House to have a specific debate on healthcare support workers. The amendment is very much a statement of principle and we will come on to social care workers in a later debate. At heart, this debate is about standards of care in the NHS and the independent sector. We should start by acknowledging the huge advance that the nursing profession has made in the past 20 years. The noble Lord, Lord Newton, is no longer in his place, but I pay tribute to him and the noble Baroness, Lady Cumberlege, for the work that they did to enhance the role of nurses with nurse prescribing. We know that they have taken on much greater responsibility since they became, essentially, a graduate profession. The problem we have is that at the same time there has been mounting concern that basic standards of care have been lost sight of. The noble Baroness, Lady Emerton, referred to the first Francis report into Mid Staffordshire. It illustrated concerns about poor basic nursing care, denials of dignity, issues around nutrition and hydration and evidence of unacceptable standards of care. These concern support workers as well as qualified nurses. There are big questions about nurse training and qualifications. I, for one, believe that there is a problem with universities and the emphasis that they give to academic and research-based training as opposed to practical training. These issues have still not been resolved satisfactorily. But there are also real issues about healthcare support workers and, as my noble friend Lord Turnberg said, the argument for statutory regulation has become quite persuasive. We have 200,000 healthcare support workers, give or take a few thousand. Most of them do a great job, but there are real concerns about the quality of work that is done by a few. As the noble Lord, Lord Patel, said we have had the benefit of two seminars in the past week or two, which the noble Earl, Lord Howe, kindly arranged. Yesterday, we were told that it was all down to a risk-based assessment, but the people doing the basic care are these healthcare support workers. There is a real issue of risk. The department has put forward a fivefold argument in favour of a voluntary approach. First, statutory regulation of nurses has not prevented problems. Secondly, the statutory regulation of healthcare support workers is not proportionate. The department refers to the rapid turnover of support staff. Thirdly, it is really a problem of contracting, poor management and poor supervision of healthcare support workers by professional nurses. Fourthly, the Council for Healthcare Regulatory Excellence, as we heard from my noble friend, will accredit voluntary registers. Fifthly, perhaps the noble Earl will offer some kind of review after a period of time. I will take those one by one. I fully accept that the statutory regulation of nurses has not prevented every single problem that has arisen in the health service, but that is surely because there are some wider issues to do with training, to which I have already referred. But my goodness me, statutory regulation has none the less provided tremendous safeguards for patients over many years. On the question of proportionality, I respectfully disagree. The fact is that healthcare support workers seem to be taking on more and more responsibility up and down the country. The noble Earl will know that the efficiency saving challenge for the NHS is a tough one. There are some indications that this is squeezing nurse staffing ratios. Inevitably, if that happens, more responsibility will be placed on healthcare assistants. On proportionality, if the argument is that we do not need a statutory register because we can have all these voluntary registers, I would turn that around. If in fact the noble Earl is promising us a voluntary approach that will cover all healthcare support workers at least in the NHS, why on earth not have a statutory register? If you are going to go to all the effort of setting up the healthcare regulatory body, chaired by my noble friend, and of having a number of different voluntary registers— I presume that they will have sanctions because there will be no point in having them unless there are sanctions—what on earth is the point of stopping there, because all the work will have been done? I suspect that we will find that the impact of the voluntary approach is patchy. That is the big problem. Let us take the issue of contracting, on which the noble Lord, Lord Kakkar, asked some very pertinent questions. Can we be assured that commissioners will insist that all providers ensure that their healthcare support workers are on the voluntary register? That is a very good point. But can the Minister go on to say that he will insist in the standing rules that all healthcare support workers are on the voluntary register? If he says that he will insist, then why not have a statutory register? If he will not insist, we will see a patchy response. Of course, none of that will cover the most vulnerable sector of all—nursing homes. We know that, for much of the time during a week, 24 hours a day, the residents of nursing homes are almost wholly dependent on healthcare support workers. This is surely the most vulnerable part of the system. Finally, on turnover and proportionality, the noble Baroness, Lady Hollins, said it all. She said that rapid turnover was symptomatic of the problem that we have with healthcare support workers. I would argue that one of the great building blocks in boosting the training and status of healthcare support workers would be to introduce statutory regulation. For me, that is probably the most persuasive argument of all. The noble Earl may offer some kind of review, but, frankly, the time for reviews and for voluntary action has gone. All that could have happened, but it has not, and we have an immediate problem of standards and patient safety. My noble friend Lord MacKenzie said that the amendment is proportionate and is about patient safety. It deserves support.