UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE
To be published as HC 920- i

House of COMMONS

Oral EVIDENCE

TAKEN BEFORE the

Health Committee

NURSING

Tuesday 22 January 2013

CAROLINE ABRAHAMS, MICHAEL WATSON and JOANNA PARKER

JANE CUMmINGS and PROFESSOR VIV BENNETT

Evidence heard in Public Questions 1 - 100

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Tuesday 22 January 2013

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Andrew George

Barbara Keeley

Mr Virendra Sharma

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston

________________

Examination of Witnesses

Witnesses: Caroline Abrahams, Director of External Affairs, Age UK, Michael Watson, Director of Advice and Information, the Patients Association, and Joanna Parker, South West Project Manager, the Patients Association, gave evidence.

Q1 Chair: Good morning, thank you for joining us and apologies for keeping you waiting a few minutes beyond the announced starting time. Could I ask you briefly to introduce yourselves so that we know who we are talking to, perhaps starting with Joanna Parker?

Joanna Parker: Good morning. My name is Joanna Parker and I work part time as a project manager in the south-west with the Patients Association.

Michael Watson: Good morning. My name is Michael Watson. I am the director of advice and information services for the Patients Association, which means that I am responsible for our helpline and our campaign and media work.

Caroline Abrahams: Hello, I am the director of external affairs at Age UK. My name is Caroline Abrahams.

Q2 Chair: Thank you very much. I would like to begin, if I may, with a general question setting the background to this evidence session. We have arranged it because there has been increasing coverage in the printed media, in the electronic media and public discourse in recent times concerned less about precise clinical treatments when a condition is identified but more about the continuity and the quality of the care in the broader sense that is provided in our health and care system. I would like to begin by asking you whether you think that is a perception that has developed and, if so, what you think are the principal reasons why it has developed. Perhaps we will start with Michael Watson.

Michael Watson: I think it is a perception that has developed because it is the reality on the ground. The Patients Association first published a report into our concerns about care in hospitals in 2009, which was a publication that included 13 of the worst accounts of care that we had heard over our helpline stretching back over a period of a couple of years at that point. We were inundated after that with calls from people who were extremely concerned about the care that their relatives had received in hospital, so we published a similar report in 2010, at that time only including cases that had been treated in the preceding year to the publication of the report. We thought at that point that we may have already raised the issue and had already reached the height of concern, but, again, we were inundated and have ended up publishing similar reports in 2011 and 2012. So our work and the work of Age UK and of many other charities or organisations, like the CQC and the Ombudsman, which have published reports with concerns, has led to that perception in the media, but we do believe that it is rooted in a reality that a minority of care that occurs in hospitals is of a standard that is vastly unacceptable.

Q3 Chair: You have clearly published stories of individual cases where that is indisputably true. Do you have any evidence from your records or from what people have said to you that this is a trend, or is it simply a spotlight being focused on something that has, in truth, always been a problem?

Michael Watson: In the last two years our helpline has received over 1,600 cases of patients or relatives contacting us with concerns about the care that they have received. The care concerns broadly have four trends around poor communication, failure to help patients that need help to eat and drink, to help patients with their toileting and failure to provide adequate pain relief. One or more of those factors are involved in every one of those 1,600 cases that we have heard. We never say that our helpline gives a complete picture of everything that is happening in the health care system, but we think that 1,600 cases over two years indicates that there is a problem. We do not believe, by any means, that everyone who has bad care phones us, so we think it is a wider problem than we hear about. Obviously that is a minority, but it is a minority that should not be allowed to continue.

Q4 Chair: Can I ask the same questions of Age UK?

Caroline Abrahams: Absolutely. We established the dignity commission, together with the NHS Confederation and the LGA, in 2011, very much because of what you have just been saying-the catalogue of reports and also anecdotal evidence from individual older people with whom we work. We noted that much of what was said in terms of the evidence that we received on the commission was similar to what you can read in reports going back 30 years. So clearly this is not a new problem. It is ever so hard to know whether it is getting worse or not. It is a serious and systemic problem in the sense that by no means everybody receives poor care, fortunately, but enough people seem to so that, among older people, it is now part of the conversation. When we are talking to our 170 local Age UKs, we certainly find that they are very aware of it and are made very aware of it by the people with whom they are directly engaging. Maybe that is just because we have more older people, so more older people going into hospital and therefore more people to experience it, but it is very difficult to know, I think. As far as I am aware, there is no credible quantitative evidence to demonstrate that it is getting any worse.

Q5 Chair: Joanna Parker, would you like to comment on this from your perspective?

Joanna Parker: My perspective can only be from my contact with the projects over the past 15 months, in the south-west mainly. The projects are trying to understand the patient experience in various settings in the acute hospitals, interviewing the patients and talking to them and also talking to their carers. Inevitably, most of them will say things like, "Everybody has been very kind, but-", and then there will be some things that have happened that they are not so happy with. Very rarely will they say, "I was in last year and it is worse this year." So it is difficult for me to be able to say whether I have noticed a trend or not. Certainly, patients themselves have not said that. In fact, the vast majority of them have had a good experience. That is what they have reported.

Q6 Chair: Briefly, before I open the questioning to others, are there any themes that come through that you would want to focus on, repeating around the patient experiences, that are the reasons why the experience of care has not been as they themselves and we would want?

Joanna Parker: It is what Michael has already said that has come through the reports, around the fundamentals of how care is delivered, communication-and actually communicating with compassion-with patients around their relief of pain, assistance with their needs and also ensuring that they have adequate nutrition and hydration as well. Some of the work that we have done has focused specifically on patients who have difficulty in expressing themselves, whether they have dementia or they have had a stroke. One of the tools that we have used that has proved very powerful in actual fact is called the Quality of Interaction Schedule, which has been used extensively in Scotland and elsewhere. It started with caring for people with mental health issues and has since been changed to be able to be used in acute settings-a valid and reliable tool. It involves nonparticipant observation of the interactions between staff and patients. There are usually two observers over a period of time. You find you very quickly become the wallpaper, and staff do not realise that you are there.

The quality of the interaction is coded as to whether it is "Positive Social"-or compassionate-"Basic Care or Neutral", or poor care, "Negative" care. The vast majority, in the two places where we have been trialling it at the moment, has been "Positive Social". We have also done some work with members of staff joining the nonparticipant observation. Having the time to really listen and hear what the patients say, understand the interactions and take time to reflect on that has been quite an eye opener for them. Staff can be full of good intentions, but they are busy and do not necessarily realise that how they speak to people or do not actively listen to them can have a huge impact on the patient and their outcomes. The work has been very well received. It has to be seen as just one part of a different method of looking at improving patient experience, but it has been very powerful.

Caroline Abrahams: I agree with what my colleagues have said in terms of the typical complaints that people have and the themes around which they tend to cluster. But I think, underneath that, there is a bit of a sense that people feel overlooked, ignored-not noticed really-as though the world is going on around them and people are too busy. I think this is quite stark often for carers and visitors who may come and visit, see a situation they think is completely unacceptable-such as a person being left for a long time with no clothes on in full view of everyone else-and feeling unhappy about that and upset but it not appearing to have triggered the same kind of response among the professionals around them. That is very difficult for carers and undermines their confidence even if the person they are visiting appears to be being well looked after. That adds to a general sense of concern and lack of confidence in the quality of care that the person they are visiting might experience as soon as they have left the room. So I think it has a broader undermining kind of effect really.

Q7 Andrew George: In terms of the impression that people have, particularly from many media reports, it appears that the primary focus of this is poor nursing care. It is nurses and, by association, registered nurses that are copping the bad press. As far as your understanding of the kind of complaints that you deal with is concerned, do you think that those who are making the complaints or observing these situations are clear about the distinction between care assistants and registered nurses, the role of social care and indeed the role of the doctors in this as well?

Michael Watson: I do not think that the patients or relatives that contact our helpline would ever consider the care that is being delivered on wards to be under the auspices of doctors at all-though I think they would consider them to be accountable for checking whether that care was good enough or to raise concerns if the care was not good enough-and doctors are seen as entirely separate.

The other element of your question which is interesting and which has not been covered yet is healthcare assistants. Our bigger concern is that patients on the wards or relatives visiting are not aware of who is a healthcare assistant and who is a nurse. That line is becoming more blurred. Of course, healthcare assistants are not regulated, not checked in the way nurses are and-based on the anecdotal evidence that we are hearing and things that other agencies are saying-are being asked to do more and more tasks that would traditionally be nursing tasks. That is a big concern for us in terms of accountability and ensuring that the people who are doing these tasks are properly trained and regulated.

Q8 Andrew George: Can I ask it a different way? Are there ever circumstances where, with complaints that come forward, the complainant is absolutely clear about the distinction between a care assistant and a nurse?

Michael Watson: It depends upon the nature of the complaint. If we are talking about handling the fundamentals that I talked about earlier-the toileting and the helping with eating and drinking-I do not think patients and relatives make a distinction. They just want those fundamentals to happen. They do not know who should be doing them, do not know when they happen badly who is doing them badly or when they happen well who is doing them well because they just want them to happen. Where we do see a clear distinction between nurses and healthcare assistants is where a relative will come into the ward and go to the nursing desk to make a complaint about the care that is happening or the fact that their mother is being ignored or has not had help to go to the toilet. At that point, if they say the nurses were dismissive or not willing to consider the complaints or said that they would sort it out and did not, they are quite clear that it is the nurses they have spoken to.

Q9 Andrew George: A moment ago you were more or less exonerating doctors from any responsibility for these failings and yet the case of Stephanie Walford in your 13 isolated incidents report clearly identifies that there was a failure on the part of the doctor in that case to properly assess the patient and then, therefore, because of the lack of communication, the patient was put at risk of being misprescribed. In those circumstances-and, indeed, I understand there is another theme, which is pain relief-clearly there is an interface between care and the role of the doctor in both diagnosing and prescribing the appropriate treatment. Is that not right?

Michael Watson: Yes, that is absolutely right, and I would not at all exonerate doctors. I think patients exonerate doctors-and I do not know if it is the tradition in the way the NHS is set up-and they are somehow seen as removed. For example, the CQC inspections in 2011 in one hospital turned up the fact that one doctor was prescribing water because he did not think the nurses would give the patients water unless he prescribed it. My argument there would be that that doctor should have been raising those concerns at a wider level if he had concerns that nurses would not be doing something as basic as giving patients something to drink, rather than prescribing it and then thinking that that tackled the problem.

Q10 Barbara Keeley: The chief nursing officer has recognised the importance of delivering care to older people with dignity and respect. So we have the words around that, if you like. Do you think the reforms that are outlined in the Government’s strategy and vision for nursing are sufficient or do you think there are other changes necessary beyond what is outlined there?

Michael Watson: They would go a long way to tackling the problem along with other work that has been published by the Nursing and Care Quality Forum and all of the reports that have come out and suggested a way forward. It will take some time to be able to measure whether they are working, and our concern is that at a time when, through demographic changes, financial pressures and everything else, the NHS will naturally come under more pressure, this is going to be a difficult time to turn around areas that have a culture of poor care. But I think that they are sufficient if they are able to be implemented, and if there is a sufficiently robust inspection regime to come after them to ensure that they are being implemented, and that where there continues to be bad or poor care it is identified and tackled.

Q11 Barbara Keeley: You mentioned various pressures on the NHS. Do you think that is a reason or excuses some of the things you touched on, not listening or-

Michael Watson: No, I do not, because, as has already been said, this is a problem that has been going on for a number of years. I do not think that it is an excuse. Something that the patients tell us all the time on our helpline is that, when they have gone to the nurses, they have been told, "We do not have enough staff on today to help your elderly father to the toilet." It may be an excuse on that particular day, but for the NHS, for a healthcare system in the 21st century, it is no excuse.

Caroline Abrahams: Our point of view would be that the issues that we are talking about today are a symptom of a wider problem, which is the struggle currently of the NHS to come to terms with an ageing population. While we do not get complaints about doctors, what we certainly do see and have done work on is the difficulty that older people have of accessing appropriate treatment. We have done reports recently with the Royal College of Surgeons, for example, and it is fantastic to see them taking this subject up and wanting to run with it. However excellent the Government’s plans around nursing might be, they sit within a much broader context, both financially but also attitudinally, and there is lots more that needs to happen on every front so that when older people do go into hospital they can be assured that they will receive good care because the whole system is geared up towards their needs. They are, after all, already 60% of the people in hospital, and that number is only going to increase over the next few years.

Q12 Rosie Cooper: Good morning. I suppose for a lot of people out there, there seems to be a lot of talking, a lot of reports, a little action but very little real change. We are still getting reports of poor care, of neglected elderly, frail patients. Obviously, people will be rather nervous, preFrancis, of recommending or doing stuff in case something that they suggest is rubbished in that report, but the NHS Commissioning Board does not seem to want to get into stated ratios of patients to staff. I believe they would be held accountable for sticking to those ratios and ensuring that people were there to provide care. I understand there is a question of affordability, but do you think we should be moving to the point where we say one member of staff to 13 patients-or whatever that is-is not acceptable?

Joanna Parker: Understanding the work force like that is probably more difficult at a national level than it is at a local level. There are so many factors to take into account. First of all, do you have a reliable tool that helps you to work out the ratio? You need to look at the acuity of the patients, the complexity of their needs, and those change, obviously, as patients come and go. It probably would be helpful to have some broad parameters, and certainly I know the Royal College of Nursing have set some, but to manage it on a daytoday, weektoweek or monthtomonth basis, it needs much more of the local knowledge and understanding of the sort of patients that are being cared for and the context in which they are being cared for. So I do not know how helpful it would be to say there should be x number of staff for x number of patients. Where I do think it would be helpful is that the evidence is there to demonstrate that with care delivered by registered nurses-and it is common sense really-there are better outcomes in terms of morbidity and mortality. So whatever is used to determine staffpatient ratios should certainly have a solid evidence base and it should not be something that is set in stone. There needs to be the fluidity around it to be able to respond to patient needs.

Caroline Abrahams: Our views are rather similar in the sense that-and I quite understand the rationale for making the argument for a ratio-our worry would be that it would become a race to the bottom and would rapidly become a sort of maximum rather than a floor standard, as it were. If you were going to do that, you would need to think very carefully. The other point is the one my colleague has just made. I know some academics say that, historically, care for older people has often relied more on unregistered nurses, which is to underestimate the complexity of nursing some older people with complex needs and comorbidities. Therefore, if you are going to think about numbers, you also need to think about the skills mix at the same time.

Q13 Rosie Cooper: If I could develop that a little, yesterday I heard somebody say they had spoken to nurses who were under pressure in hospitals and wards nursing elderly patients and they were asked, "Why is there a great difference between care provided in the halcyon days, when everyone said it was fantastic, and now?" Apparently a nurse replied that then they did not see elderly patients having been through complicated or difficult operations as they do now, as if that is an excuse. So nursing-that idea of complexity-would only ever be an absolute minimum ratio, not the drift to the bottom. But, if you do not have that, and you have this complexity, how do staff manage?

Caroline Abrahams: The only other point I would make about that is that our report with the Royal College of Surgeons showed that there should be a lot more operations going on with older people. That is a whole different set of issues, but again part of the same problem, which is that of not really looking at older people objectively, understanding their needs and being able to meet them just as you would with any other patient.

Q14 Dr Wollaston: The final report for the Commission on Dignity in Care for Older People focused very specifically on the relationship between staff, nursing staff as well, and patients, and I am wondering what evidence there is around the link between failures in clinical care and failures in the treatment of older people with dignity. Are they very closely linked or do you have any examples where people get otherwise good care but are unhappy with, if you like, the dignity they receive from staff?

Caroline Abrahams: It is more the other way round. One of the things that did come out of the dignity commission work was that, if the care is that poor, so people are becoming malnourished, not getting water, they are being left and are not moved often enough so that they are developing pressure sores and so forth-neglectful care of that kind-that can inhibit somebody recovering and being able to get back on their own two feet, or even get out of hospital at all. There is definitely a correlation, I think, that way round, that it can lead to poor health and undermine what might otherwise be quite good clinical care. I do not know about the correlations the other way round. We can look and see, and I can come back to you if there is evidence of that. We can look.

Michael Watson: I cannot say specifically about the correlation, but something that we do hear quite frequently on the helpline, particularly around elderly patients, is from clinical teams, physiotherapists, doctors or whoever, who will see a patient one day and then not see them for three or four days and come back and say to the relatives, "I can’t believe the decline. I can’t believe what has happened. I can’t believe how quickly they have gone downhill." In the meantime, the relatives have been complaining that their elderly patient has not been getting help to eat or drink, or has had to go to the toilet in the chair they were sitting in and has been sitting in it for hours and developed bed sores and all of those kinds of things. I cannot give you any scientific link, but that is something we hear time and time again, and it just seems to me common sense that good clinical care, good aftercare and good care in general go hand in hand.

Q15 Dr Wollaston: How closely does physically caring for people’s needs correlate with respect? Are they the same group of nurses who are delivering poor respect? Is it a failure across the board?

Michael Watson: Certainly, in the cases we hear of on our helpline, what patients say to us is, "Nurse C, or whoever, and her colleagues on that particular shift." We hear quite often, for example, that there are problems with one shift and not problems with the other. The problems with that one shift will be poor care in general but will also be things like, "The nurse comes in and abruptly grabs my mother’s hand, takes her blood without even talking to her, slaps her hand down on the bed and walks out without saying anything." That is a respect issue. So I think it all goes hand in hand; it is all one and the same.

Q16 Dr Wollaston: I was interested in what Joanna Parker was saying earlier as to your study about getting nurses to listen in to conversations. When they did that, did their care standards improve as well as their standards of respect and interactions?

Joanna Parker: We have not gone back to check yet.

Dr Wollaston: Thank you. I just wondered.

Q17 Valerie Vaz: You mentioned compassion a lot of times. I want to take you back to the "Compassion in Practice" document, the 6Cs and what your view is on how we implement those. Do you want to start from left to right?

Joanna Parker: I think nurses will welcome the 6Cs in terms of the values and behaviours that they probably all espouse and will welcome the opportunity to be able to change the way that they can work, because I think the vast majority of nurses want to give the best care that they possibly can. The demonisation, almost, of nurses is obviously, or can be, counterproductive.

Before I came today, I tried to map out some of the work that the Patients Association has been doing against the 6Cs. Certainly, there is a whole raft of work around working to provide a positive experience of patient care. There are some really good examples that have come back from our CARE Campaign and I know that that report has been shared with the Committee. Certainly, in terms of what is being done with some of the local programmes and projects, they also fit, obviously, very well with the positive experience of care.

One area where we have done a different piece of work is with the Peninsula medical school, where there is a specialist study unit that one of our members of staff will be taking forward, which is to work with first year medical students, and hopefully to bring in other undergraduate students as well, very much using the QUIS-the Quality of Interaction Schedule-and also our care audit where they will be nonparticipant observers on wards and will have an opportunity to watch, listen and to reflect. Hopefully, that will become part of mainstream education not just for nurses but for other healthcare staff as well.

The importance of embedding the 6Cs in undergraduate education, in continuing professional development and allowing nurses to have time to reflect on their care and to continually learn, network, and to share good practice and innovation will be really important. Certainly, we have provided opportunities through the projects we have been doing and the conferences that we have held, and I think there are plenty of opportunities for nurses to share things in this technological age; but sometimes it is almost as if they need permission to do that because they are so busy with everything else that they are doing in terms of delivering care. You can go to one acute trust and discuss some of the things they have been doing and go to another and find they are doing exactly the same but they have never shared it. Or you can go to somewhere and talk about some of the project work they are doing and they are surprised that we consider it exciting and different, because it has been their norm. So, in terms of cultural issues and spreading good practice, there is a lot that can be done around that as well.

Q18 Valerie Vaz: Is that something for the Commissioning Board to look at?

Joanna Parker: I think it will involve other bodies as well, definitely.

Q19 Chair: Which other bodies?

Joanna Parker: There is education, Skills for Health, so that is for nonprofessional staff, certainly around how inspections are carried out, to name a few.

Q20 Chair: What about the NMC?

Joanna Parker: The Nursing and Midwifery Council, yes.

Chair: Possibly.

Joanna Parker: If we followed through with our concern about regulation for healthcare support workers, then there is certainly a big role there for the Nursing and Midwifery Council.

Valerie Vaz: Mr Watson.

Michael Watson: The only other thing I would add to that, to emphasise, is the need for powerful leadership at ward level. I was reading through one of our reports last night and one of the things that struck me is the frequency with which the relatives who are speaking about the poor care their patients received refer to the good care that they received in other wards or even other shifts on that ward, and they all identified the leadership: "There was a different sister on today and she was fantastic and everything was running like clockwork." To build on what Joanna said, the leadership is key at ward level.

Caroline Abrahams: If we are talking about driving transformational change, which I think we are, then obviously the role of firstline managers, essentially the people on the wards, is crucial. Also, you need it top to bottom, though. You need boards to be talking about this and senior managers. The messages have to be consistent right the way across the system. Equally, in terms of the development of the nursing profession, it is about how you recruit, the messages you give out to people when you are seeking to recruit, the initial training, how they are managed and their ongoing professional development. It is the carrots and the sticks. It is how the conversation goes. Good as the 6Cs are-they are a bit like the five As we had in the dignity commission, and you can do it in lots of ways-the real trick is, "How do you get people to buy into that, to really change what they do, and to feel good about it?" It is not about bashing people over the head from the top. It is about getting alongside them, the role of peers working together, so that people start to feel good. I do not think anyone goes to work in these jobs to do a bad job. People want to do a good job, but, for whatever reason, they are not doing that at the moment. It is a longterm process and it needs real welly from the top right down to the bottom.

Q21 Valerie Vaz: I want to tease out something. If you go to a theatre, you get nurses who are highly skilled, disciplined and have the right attitude. That seems to work and it has to work. Is that because of the leadership of, say, the surgeon in the theatre?

Caroline Abrahams: I do not know the answer to that, but what I do know is that there is lots of evidence that work with older people on wards is viewed as low status, not very attractive and not very exciting. The whole culture of people going into that sort of work probably is not very positive in the first place. Some people might suggest that you, therefore, do not necessarily recruit the most ambitious, the most competent and careeroriented people to do it. I am not saying that is true, but it is possible that the best people do not always want to work in that area. We have to change that. It is really important that that changes.

Q22 Valerie Vaz: It is a skills mix, isn’t it, and now that we are moving towards, as you say, lots more elderly people, there is a skill to dealing with elderly people?

Caroline Abrahams: Absolutely.

Q23 Valerie Vaz: So is it a question of more training-maybe a rotation?

Caroline Abrahams: Yes, and it is not just nurses. When we did the Royal College of Surgeons work, I was staggered to be told that doctors receive seven hours-I think it is-in geriatric training as part of their education. I am sure they learn lots of other things as well that are highly pertinent to looking after older people, but the senior doctors in the room, when we were talking about this at a seminar, were saying that it absolutely is not enough. We need a total step change in the amount of time and energy spent helping new young people to think about what they are actually going to be facing when they go on to a ward, into a hospital, and it all needs updating and modernising.

Q24 Valerie Vaz: I have a last question on your observers. Do you see that as a longterm plan and could that be done without costing the NHS any money?

Joanna Parker: The tool is there. It is reliable and validated. It has been published and it is there for trusts to pick up and introduce if they wish.

Q25 David Tredinnick: There seems to be a consensus that personal responsibility, leadership and accountability are necessary values to deliver patientcentred care, but what needs to be changed to instil these values within the work force?

Caroline Abrahams: That is the $60 million question really. If we knew the answer to that, we would all be sorted. I think it has to start from the top. It is good to hear the Secretary of State talking about these issues. This has to be taken seriously by political leaders, by professional leaders, the Royal Colleges and the professional organisations. Some of the things that the Royal College of Nursing have said have been very helpful and constructive. What we do not want is people being defensive about the issue but rather accepting that it is something that is not as good as it should be and that we all have to work together to fix it. Organisations like mine and my colleagues here can do quite a lot from a bottomup point of view to help galvanise action locally, and I am sure we could do more in a more coordinated way.

Q26 David Tredinnick: You are saying you need a lead from the top and that is essential, which we have with the 6Cs.

Caroline Abrahams: Yes, that is great; it is a start.

Michael Watson: I would add to that-and I completely agree with all of that-that, as well as that lead from the top in terms of policy, there needs to be a lead from the top in terms of individual trusts. Where trusts are made aware of patient concerns of poor care, rather than being defensive about that and seeing it as something that they need to naturally row back against and draw up the drawbridge, so to speak, and try to defend themselves, they need to acknowledge that, look into it properly and identify whether the concerns are legitimate. The Patients Association helpline helps patients take their concerns through the NHS complaints system, and, even after all of the reports, all of the concerns, the CQC reports and everything that has happened, I am still staggered on occasion by the way that trusts respond to patients or relatives that raise perfectly legitimate concerns. Surely, the onus has to be on those trusts-we are not asking for an instant admission that everything was wrong and that they completely agree with the patient-at least to have the mindset of, "We will go away and look at this, and, if there is poor care, we will tackle it properly, and, equally importantly, we will make clear how it has been tackled and how we will stop it from happening again."

Q27 Chair: May I challenge also one of the expectations, which Caroline Abrahams offered, that this needs to be a longterm project? I wonder about leadership from the top. I acknowledge that is desirable, but actually even more important is leadership within the hospital, and indeed within the community setting. There is a lot of talk this morning about hospitals and acute trusts, but this is equally important in the community setting. Straightforward leadership can achieve "transformational change", to use your phrase, much more quickly than sometimes we expect.

Caroline Abrahams: Yes. I am sure you are right. What I really meant was, in terms of the formation of professionals, that is a longterm process because you are talking about who is coming in now as well as about trying to support those who are currently in roles. We are thinking about the nurses of tomorrow. I suppose what I am thinking about is, absolutely, without that leadership at the top, you cannot get anywhere and you can make huge differences. But it is also about sustaining those changes so that people routinely will do the right things over and over again. It would be lovely to be in a position where we had changed things but were a bit worried about them slipping back. That would be a nice problem to face a bit later on perhaps. My concern is about sustaining it for the future.

Q28 David Tredinnick: Moving on slightly from this line, I want to look at the scope of nurses’ work and ask whether you think that the work of nurses as defined is correct. Do you think that there is some work of healthcare workers-Michael Watson’s point-that nurses should be doing or do you think you should be taking from the doctors?

Joanna Parker: That is difficult for the Patients Association to answer other than to say, as I have already mentioned, about the evidence to demonstrate that a registered nurse is likely to deliver care that has better outcomes for patients. That would raise a question then about dilution of skill mix and ratio of healthcare support workers and nurses. There is a difference in delivering fundamentals of care. Whether you are helping somebody to have a wash, encouraging them to eat or making sure they have enough fluids-and they might sound like simple tasks, but they are not-there is a big difference between having an educated doer, a registered nurse, and somebody who has been trained. That is not to say that healthcare support workers cannot deliver good care, because they can, but it is about how that is supervised. In terms of altering the scope of practice, I do not think that the Patients Association is in a position to comment on that.

Caroline Abrahams: I am sorry, but we are probably not in a very different place in the sense that what we see is what happens when it does not work as well as it should. What I would say, though, as a matter of principle, is that I am sure there would be some merit in experts sitting down with professionals and thinking about what is the overall resource that we have in a particular ward, for example, and thinking a bit about it from the point of view of the older person: what is this person’s needs, how are we currently allocating that resource, could and should we be doing it slightly differently, and are there other resources we are not tapping that we should, like volunteers, and so forth?

Q29 David Tredinnick: I think you are getting to where I am trying to get you to, and that is whether or not nurses should be using some of the skills that go beyond the formal box of skills that they have been given, which they may have learned somewhere else. Going back to something that was said earlier on when we were talking about taking a lead and the importance of leadership and the Chair’s remarks about transformational change, I wonder if any of you have had a chance to look at the Patient Protection and Affordable Care Act in the United States. We have just had the reelection of the president. This is widely known as "ObamaCare", and this Act specifically mentions complementary and alternative medicine and integrative healthcare, as it calls it-we deal with integration a lot in the Committee-in seven different sections throughout the law, in the new Act in America, which comes into force in 2014. This was possibly based partly on the 2011 consumer reports that found that 38 million Americans make an excess of 300 million visits each year to CAM specialists, including acupuncture, massage therapists and chiropractors. It is the first time in US history that CAM and integrative medicine practitioners have been included in a national healthcare law and this is a fundamental shift in direction. Do you think that nurses who are qualified in, for example, aromatherapy, therapeutic touch or any other disciplines that they did not receive in their formal training should be able to deploy them in their work in the hospitals?

Caroline Abrahams: Age UK does not have a position on that issue, which perhaps will not surprise you.

Q30 David Tredinnick: Surely you must have a view. You are working with these people all the time. We have just had a huge change of policy in America and very often we follow the lead there. What do you think about the-

Caroline Abrahams: I would say two things.

David Tredinnick: Let us break some new ground. I am giving you a chance to-

Caroline Abrahams: It is always good to look abroad and see what other people are doing and there is some good practice in America that is definitely worth learning from. Some of their health providers, like Kaiser, are very proactive and achieve wonderful outcomes. There is a lot we can learn from them. At heart, what we are really talking about and what would make the biggest difference is not whether someone has done that extra training, but the attitudes that they bring with them when they go to work in the morning and what they think is important in terms of doing a good professional job. It is having all the Cs, the courage and the commitment, to go on doing that over and over again, even in very difficult circumstances with perhaps somebody who is not very easy to work with. That is the reality of trying to nurse some very sick and elderly frail people. I think it is more about those things. But we will always look with interest at what is happening in America, or we should.

Michael Watson: I think that is exactly right. We do not have a position on that either, but it is not just about the attitude of the individual, although that is obviously incredibly important. It is also the workplace that they are going to be going to work in and the culture that exists there. We need to tackle those two strands, I think, before we start to look at the skill set and what else we can do.

Q31 David Tredinnick: Chair, I have one last question on a totally different subject but it has come up this morning. That is the issue of water and the use of water. We have heard of a doctor prescribing water, we have heard of nurses dealing with elderly patients thinking it is a low status occupation, and there seems to be a fundamental problem about dehydration in some hospitals with not enough priority being given to fluids getting into patients. We have heard already this morning how a patient can change in a few days. In my own experience of this, it is definitely the case. Do you think there should be a better system for regulating the input of fluids in elderly patients?

Joanna Parker: I think you will find that most acute trusts have now introduced what is called "intentional rounding" or "comfort rounds", where nurses go round their patients on an hourly or twohourly basis with the intention of ensuring a number of things, which might be the position to help prevent pressure ulcers, for example; whether the patient requires any pain relief; but also, most importantly, to check whether they need a drink and encourage them to have some fluids. That has made a huge difference in terms of patients being able to access a drink because it is physically offered to them and they are encouraged to have a drink. There are notes made of the intentional rounding. I do not think it requires that there is some sort of formal form filling-out for each individual patient.

The only thing that I would raise about it is that, as one of the projects in the south-west, I undertook a nutritional audit, where I did five observations of different meal times. What tends to happen with jugs of water on the hospital wards, which are quite warm, is that they are cleaned and refilled in the morning and they can often sit there till the evening. Patients actually find that warm water quite unpalatable. It only takes a simple act to ensure that they can have cool, fresh water to drink. What I did find out was that sometimes it is the systems that let them down. The patient is given a meal on their tray. Then I pointed out to the staff, "Why not pour them a glass of water and give it to them?", and I was told, "But the trays are collected by domestics. If the glasses are left on the trays, they disappear to the main kitchens and we do not have enough glasses on the ward for patients." So sometimes a simple suggestion exposes where there are some system failures that could prevent people-

Chair: It should not need much to sort that out.

Q32 David Tredinnick: So what you are saying is that patients could be dying for the lack of a few beakers.

Joanna Parker: No, not with intentional rounding. The introduction of the intentional rounding has made a huge difference in terms of ensuring that the vast majority of patients have an adequate fluid intake now.

Caroline Abrahams: The only other thing I would add is that it is really important, too, that people are screened when they go into hospital because, quite often, they will be malnourished or dehydrated when they arrive, and then you need to keep on screening them and supporting them to eat and drink as they are there.

Q33 Andrew George: I am getting an impression of where we are going with the discourse here. The impression I get-because I want to kind of get an idea from your expertise as to why you think there is a failure in those areas of dignity, compassion and consideration for patients-is that there could be a range of reasons for it. It could be that the nursing profession is attracting the wrong type of people, that, in fact, nurses simply reflect a change in society as a whole, there is a failure of training, or there are perhaps other reasons for this failure. I think it was you, Caroline Abrahams, who said that you felt that the nursing profession was simply attracting the wrong type of-un-ambitious-people.

Caroline Abrahams: I am sorry, but I did not say that.

Q34 Andrew George: Okay. I am trying to get an impression of where we are going here, but I think earlier you were suggesting that one reason why there was a failure in this area might be that it is attracting the wrong, or not necessarily-

Chair: You said that care of the elderly-

Caroline Abrahams: It is that bit of nursing that is not viewed as attractive.

Q35 Andrew George: Even so, it may be a pattern that is emerging among others, and what is required in terms of the primary means by which we can address these problems is clear leadership from the top. So we are not taking the risk of straying into areas of pontification, I want to be clear of the extent to which you, as organisations, are talking directly to frontline nurses, because it seems we are talking about them. I am sure you are talking to the Royal Colleges, but are you taking these messages to frontline nurses, and understanding and getting their feedback as far as these patterns and failures and so on are concerned? That does not seem to be emerging from what you are saying so far. I wondered if you could tell me about the conversations you have had with them.

Joanna Parker: Certainly, with the projects that we are undertaking at a local level-and this is the first time that the Patients Association has had a local presence as such-we are talking with the nurses there. We have also had a number of Partners in Care conferences across the country where we have shared what we have been doing and had opportunities to talk to nursing staff. The CARE Campaign, which we are running with the Nursing Standard-which is a popular weekly nursing journal-has something in it about the CARE Campaign and gives good examples and so on. So that is a message that we are able to use as well. The CARE Campaign also has a website and space on our website as well with opportunities to post messages and so on. As to the facetoface opportunities to talk to nurses, you are right to say that there is no simple answer to why poor care happens.

As to what the answers are, it is multifactorial, but I think observing the nurses and talking to them is one. Nursing frail, sick elderly people is not a set of simple tasks. It is far more complex than that and it can be emotionally draining. If we expect staff to care for others compassionately 24 hours a day, 365 days a year, they need to be supported as well. I think there are organisational and cultural issues that need to be addressed to support nursing staff as well. Certainly, there should be the opportunity to share where they are "allowed" to innovate, depending on their organisation, and they are excited to share what they are doing with that. So I think they are keen to deliver more than they are maybe able to do in some circumstances at the moment.

Q36 Andrew George: I am particularly interested in feedback from nurses. You are no doubt having conversations with them, from what I understand. Therefore, you are putting some of these points to them and I would be interested in what their response is to the issues of concern that you are raising. I do not know whether Michael or Caroline has any comments.

Caroline Abrahams: We interact at two levels. Through local Age UKs, we have many colleagues who are working in partnership locally in hospitals and in other settings, working alongside health professionals of all kinds, so it happens there. It also happens nationally through our conversations and work with people like the Royal College of Nursing, who have been very supportive of the work on the dignity commission and have offered us opportunities to take part in their conferences and events. We are right now at the point of wanting to take the recommendations of the dignity commission off the page and put them into action. We are working up our implementation plan. We are talking to lots of national organisations, talking to Government, and we want to see what we can do very much in support of the profession to generate improvements on the ground.

Q37 Andrew George: Can I finally put one suggestion to you briefly? One of the themes that has not been mentioned much is registerednursetopatient ratios, for example, and those being inadequate, knowing that nurses often report inadequate nursing staff levels on, for example, acute wards. The fifth of the 6Cs is "courage". Do you think that what is needed is in fact leadership from the front line, because the leadership from the top is so woeful and in denial of poor staffing levels on wards, and, indeed, it is the fifth of those 6Cs that might be the quality that is needed for nurses to stand up for themselves and to make sure that wards are adequately staffed? I am just putting that as an alternative, so in fact the leadership is vital.

Caroline Abrahams: Certainly, you need leadership at all levels. It takes a lot of courage for a professional to challenge another colleague to say, "That wasn’t as good as it should have been. We need to do better next time." If somebody said, "Is the NHS a learning organisation? Is this hospital a learning organisation? Is this ward a learning organisation?", it is a tough question to ask and people need to be prepared to ask that of themselves and be able to come up with a positive answer.

Q38 Chair: Is that what is wrong, that we think that that is a challenging and difficult concept to embrace when it is written firmly into the definition of what it means to be a professional, whether a doctor, nurse or a midwife?

Caroline Abrahams: Yes, and we are often talking about this word "culture" needing to change, but, in a way, that is just a code for something much more difficult, which is how people interact with each other, what their attitudes are and how they act on the back of that. Being able to change that is absolutely the thing that has to happen and it is very difficult, but it has to mean everybody doing their job well and taking responsibility. That has to be leaders doing their job but also the frontline professional or the healthcare assistant actually taking responsibility too.

Q39 Barbara Keeley: It strikes me that it is not just about frontline nurses and healthcare assistants-it is perhaps quite a tall order to expect them to do it-but there are nurse directors, aren’t there? The people responsible for nursing in hospitals should be saying something more about staffing levels.

Caroline Abrahams: Yes.

Q40 Barbara Keeley: I have a final point about weekend cover, and obviously this is mainly for the Patients Association. We have talked a lot about cases involving older people, maybe people at the end of their lives, their last few days, but in fact there are a couple of examples in your "Stories from the present, lessons for the future" involving young people, one young person needing emergency treatment for an asthma attack, a 15yearold on a Saturday night, and another case of a young woman with diabetes getting very poor care for her diabetic condition because there were no diabetic nurses or doctors and there was no PALS service in over the weekend. Could you perhaps tell us how the problems that patients face are exacerbated over the weekends, because if that is another specific issue then I think we should understand it?

Michael Watson: Certainly. We deliberately did include cases of younger people and also weekend care because it is something that we are seeing. We are concerned that, as the focus is on elderly care, quite rightly, we do not want those other cases to be left behind. The thing that comes through in all of our stories, and many of the other reports, is the sense of helplessness that patients and relatives have when they are on a ward experiencing bad care that they have complained about, which continues, and they do not think they can raise it as a concern any more. That is made worse at weekends because there are fewer people around to complain to. They are likely not to be seen by a doctor over the course of that weekend. Their clinical care, in our anecdotal experience from what we hear on our helpline, is unlikely to move forward over the weekend. As a result, what we hear on the helpline is patients and relatives telling us that they feel isolated on the ward, they are receiving bad care and that, ultimately, there is no one out there to help them get out of that situation. I think that is a very sad commentary on the healthcare system.

Q41 Chair: Do you agree with that analysis?

Caroline Abrahams: Yes, absolutely. Again, being ill or needing to go into hospital is not a 9to5, MondaytoFriday experience.

Q42 Chair: I am sorry, that was not the question I was asking. Do you agree that that is the perception on the ground-that everyone can accept that you are equally ill on a Saturday morning and it is equally urgent as if it is a Wednesday morning?

Caroline Abrahams: Yes, absolutely.

Q43 Rosie Cooper: Do you not think that it is the boards-the professional executive members on the boards as well as the nonexecutive directors-who are responsible and who must know that there is inadequate cover on wards at the weekend? For example, my father had a stroke about five or six years ago. He was admitted to the Royal Liverpool A and E at 20 to 1 in the morning, and the consultant in charge that weekend said, when I challenged him about his specialty because my father did not get his brain scan, that he was a person who specialised in diabetes. He was in charge of a busy A and E in a major city at a weekend. Those boards, the nonexecutives as well as the executives, know that that is the situation and allow it to happen, and some responsibility needs to be nailed at their door.

Caroline Abrahams: I totally agree.

Chair: On that note, we should say thank you very much for what you have said. You have given us plenty of food for thought. We shall reflect on it. Thank you.

Examination of Witnesses

Witnesses: Jane Cummings, Chief Nursing Officer for England, NHS Commissioning Board, and Professor Viv Bennett, Director of Nursing, Department of Health, and Lead Nurse, Public Health England, gave evidence.

Q44 Chair: Good morning. I noticed that you were sitting listening to the earlier panel of witnesses, but perhaps we could begin by asking you to introduce yourselves and then we will get straight into the evidence session.

Jane Cummings: Good morning. My name is Jane Cummings. I am the chief nursing officer for the NHS in England. I was appointed in March, started full time in June and I am responsible for the professional leadership of all nurses and midwives, with the exception of public health and social care nurses. I am also principal adviser to the Government on nursing and midwifery and a part of the NHS Commissioning Board, where I also have lead responsibility for patient safety and the patient experience.

Professor Bennett: I am Viv Bennett. I am Director of Nursing at the Department of Health and Lead Nurse for Public Health England. I have a number of responsibilities as a senior civil servant and the leadership for nurses and care workers in the social care sector and in public health. I have leadership of two national programmes that might be of interest to the Committee-the health visiting national programme and the nursing contribution to the dementia challenge. Also, in my role as Public Health England Lead Nurse, I am a member of the national executive committee. I am the lead adviser to Government on the nursing and midwifery contribution to public health and I am joint director for clinical governance in public health. I am required to declare that I also do unpaid work in the social care sector working with a group of care homes and with the Alzheimer Café Movement.

Q45 Chair: Can I start with the same question that I put to the first panel, which is, just by way of context, what your assessment is of the reality on the ground of the quality of care and the issues we have been discussing with the first panel? How big a problem do you believe it to be in the health and care system? Do you think that it is a problem that has always been there and just happens now to be in the spotlight, or do you think that there is a trend there, and, if so, what are the causes of the trend?

Jane Cummings: I think the situation is mixed. There have always been episodes of poor care. It is difficult to be absolutely clear whether there is a significant increase, and you heard earlier some varying views about that. What is very clear to me over the past few years, and since I became the chief nursing officer, is that there is a lot of very good care up and down the country, and many nurses and midwives and care staff feel, as I have already said publicly on several occasions, betrayed by the poor care that does exist at times. However, if you are a patient or you are a relative of a patient who receives poor care, the fact that the vast majority get good care means nothing to you and actually you can never make that right. So we are absolutely determined to work really hard with our professional colleagues up and down the country to try and reduce it to the absolute minimum as far as possible.

Talking very briefly about your question as to "What are the reasons?", it is clear that the NHS and many staff that work within it are under quite a lot of pressure. It is very busy. There is a significant demand on care, and patients, as many people have already talked about, have a lot of difficult and quite complex needs to address. There is also a justifiable and right expectation from people that they should get good care, and people are more encouraged now-and this is something I would support-to speak up when things do not go well and not just accept it, as in the past, as being, "I am very grateful to get any care so I am not going to say anything." So the issues are multifactorial and it is not straightforward to say it is A, B or C.

Professor Bennett: I completely agree with everything that Jane has said. In terms of the way we think about it, we are increasingly thinking of care delivered in a whole range of settings: in hospitals, as we touched on a lot with the people here this morning; and there is increasingly complex care being delivered in the nursing home sector, people who would have been in hospital being maintained there, and issues have been raised about the quality of care there and how we help those staff manage increasing complexity. We then move down a layer, where we have care homes that are looking after people who may previously have been associated with nursing homes. We have had this downward shift so that people are dealing with new levels of complexity. We know that, increasingly, we need to care for more people at home and in integrated ways.

Some of the issues that people have raised concerns about are our failure to achieve that integration, and some of the issues that were raised about communication become even more important to manage well. In the past, we have particularly not given due recognition to those carers who provide care out of hospital, both nurses and carers in the care home sector, and it relates to some of the previous discussion around the status of caring for older people.

So I think it is multifaceted. Those failures in care are never acceptable and should never be condoned. They are an affront to the nurses and carers who provide excellent care to people. We need to learn from those things that went wrong. Also, I am passionate about learning from the things that have gone right, and we need to be promoting some of the very good care we have so that it becomes universal-not variable.

Q46 Chair: One of the things that did not come up with the previous panel, which I would be interested in your reaction to, is that, very often, when you talk to clinicians-not just nurses but certainly including nurses-about the health and care system, they say that one of the causes of pressure on them, given all the pressures you have identified, is process, paperwork, bookkeeping and unnecessary records. I wonder whether that is something that you have looked at from the Department’s perspective to ensure that records-of course there have to be proper records-are kept in a way that minimises the amount of a professional’s time that is devoted to doing it.

Jane Cummings: Absolutely. We both feel really passionately about this and about using technology to deliver the best outcomes. You are absolutely right that there is a balance between the need to have good records and to be able to document how you assess patients, and the care you give them and being able to make sure that that is available for all clinicians in the team to look at and review. However, there is plenty of evidence of duplication, of patients being asked the same question multiple times, of different people recording things in different ways. We need to look at that very carefully. Certainly, staff will say that they are happy to record the information that is necessary and needed, but they only want to do it once and they want to use technology in the best way. We need to be able to use that technology so that when patients move between hospital and community, or a GP service or an ambulance service, that information can be accessed, and in a way that means safe and effective care is being provided and people are being asked things only once. Viv, I know, feels as strongly as I do, if not more so.

Q47 Chair: Before you start, it is one thing to feel strongly about it, which is good news, but what are you doing about it?

Professor Bennett: The common things are: are we collecting the right information; are we collecting it in the right way, that is, the most simple way; and are we sharing it? I think we could be challenged on any one of those. We have done a series of pieces of work, and one of the areas where this has been signalled as a very big issue is in community services, where it breeds inefficiency as well as a risk in care. People are driving 25 miles after they have written something down to enter it into a computer. So we have just published a piece of work that we did into the use of mobile technology in community settings where some of our clinicians and healthcare support workers have used various technologies for collecting realtime information. It is collected once.

There are some good practice examples, for example, in Lincolnshire, where they use one system so that it is a common record. The GP or practice nurse in the surgery can look at the record, see that the district nurse has been in the home, the district nurse can look at what the blood gases were that morning and give the appropriate care, provide the appropriate drugs and record the interaction immediately. It is on one system and it is safe. That is extremely variable. We did identify £100 million to be spent in 201314 to promote the use of technology for nurses, midwives and care staff, and it is very important that we do that. Anecdotally, district nurses tell me, "It is not acceptable that I have less technology than a supermarket delivery driver. How can that be right?" That resonates with me very strongly. It is not right; we are going to do something about it and have started to do so.

Q48 Barbara Keeley: You were probably here in the earlier session when my colleague Andrew George raised the issue of courage and nurses at whatever levels speaking out about issues such as staffing levels. Before we get too sucked into process things, it has been the case-and I have raised questions about it here-that CQC reported that 17 hospitals have dangerously low staffing numbers. I am not saying that I do not think what you have just been talking about is important, but surely one of the most important things that you both should be focusing on, particularly Jane Cummings, is the fact that we have hospitals in this country with what is talked about as "dangerously low" staffing numbers, not enough staff to keep people safe and meet their health and welfare needs. Why focus on other issues when that is the kind of elephant in the room, if you like? Isn’t that the most important and pressing thing for you, Jane Cummings, in your role?

Jane Cummings: It is one of several things. It is clearly an important area and I certainly would not want to diminish the importance of having appropriate staffing to look after the needs of the patients. However, in order to achieve that, you also need to look at a broader picture. It is not just about numbers. As we heard earlier, it is about leadership, the culture and the environment in which people work, all of which helps nurses to deliver the care better.

Q49 Barbara Keeley: Can I stop you there? You do not think it is about numbers. You do not agree with CQC that having dangerously low numbers-

Jane Cummings: No, I didn’t say that.

Q50 Barbara Keeley: You just said you don’t think it is about numbers.

Jane Cummings: No, I didn’t say I didn’t agree with CQC. What I said is that the reality is that you can have wards with exactly the same numbers of nurses and the same types of patients and a very different feel, a very different ability to treat and care for the patients and a very different patient experience. The numbers of nurses that are on each of the wards or in the community is absolutely fundamental, and it is one of the key priorities that is in the "Compassion in Practice" document, where we have been very clear that the numbers of nurses need to be evidence-based and to reflect the needs of their patients. I absolutely stand up and say that, and I have said it on public platforms and in the media on many occasions. It is also the responsibility of the organisations themselves, the boards, the directors of nursing, the organisations, to ensure that they have sufficient staff to care for their patients and it is the responsibility of the commissioners-those that commission services-to ensure that they are commissioning safe services with good outcomes. So I absolutely agree that we need to make sure that we have the right numbers of staff but we need to be evidence-based.

Q51 Barbara Keeley: How can we be in a situation where a trust, any trust anywhere in the country, with a nursing director, or where a hospital has other people who come in, such as the CQC inspectors, and they say, "This hospital has a dangerously low number of staff. It can’t keep people safe and can’t meet their health needs"? How on earth does that happen? How do 17 hospitals get to a position of having what is "dangerously low" numbers, when they have nursing directors that should turn to the boards and say, "We have a dangerously low number of nursing staff"? The rest of it does not seem worth spending your time looking at if you cannot have enough staff to keep people safe.

Jane Cummings: You need to go back and look at each of the individual cases and the reasons why they are in that position. Again, they are multifactorial, so sometimes it can be a lack of leadership; sometimes it can be absence or sickness or lack of recruitment.

Q52 Barbara Keeley: But isn’t it the courage that my colleague Andrew George talked about, that a nursing director is not turning round and saying, "We don’t have enough nurses"?

Andrew George: It is the frontline nurses often that fear the consequences of raising the issue.

Jane Cummings: But we also have lots of examples of organisations up and down the country where frontline nurses and directors of nursing have gone back and talked to their organisations and have had significant increases put in. I was in a trust not long ago in East and North Herts where I was talking to the director of nursing and the ward manager of elderly care wards. They had brilliant, really great care and were able to demonstrate what they were doing and how they were treating dementia, which many of their patients had. But they were also talking about what they had done to increase staffing. They had spent time looking at evidence, looking at the needs of their patients, benchmarking their staffing levels, and they had increased the numbers of nurses on all three of their elderly care wards. I have several examples where that is the case. So I think you are absolutely right. The courage and the commitment, following the 6Cs that we have put out there, do help a lot of organisations do that. But, in terms of the 17 that the CQC referred to, that is clearly an issue for all of them urgently to do something about it.

Q53 Rosie Cooper: I am veering all over the place with the question I really want to ask, but I suppose, as the chief nursing officer, following on from what Barbara said, frankly, for the people who use those hospitals it does not matter what the reason is, what the excuse is, what the warm words are or what the platitudes are. If they are short of nurses and it is stated to be serious by the CQC, then it is a realtime situation. So what have you done in your role, not, "It is just a responsibility of each of those organisations"? You are in a national role. What have you done about it?

Jane Cummings: We have asked our regional colleagues to look at what they are doing. Some of those organisations were foundation trusts. They have a responsibility through to Monitor for delivering safe services and they also have a responsibility through to CQC, so we have asked for updates on what they are doing and when they are putting it right.

Q54 Rosie Cooper: The CQC report was a week or two ago. How long are you going to wait for the answers? How long are patients who go to those hospitals going to be put, potentially, in danger? I do not know-I am not CQC-and you are the chief; you are responsible for the new Commissioning Board, both of you. What have you done? What are you actually going to do? What are you doing now? Why is it okay to wait for a report?

Jane Cummings: The decisions about what staffing goes into each organisation is the responsibility for that trust board.

Q55 Rosie Cooper: Mid Staffordshire: are you going to let it happen again?

Jane Cummings: No; they are responsible for the staffing that they need to put in.

Q56 Rosie Cooper: What are you responsible for?

Jane Cummings: I am the professional leader for nurses and midwives.

Q57 Rosie Cooper: And you are obviously failing because they are not doing it.

Jane Cummings: The issue for us is to make sure, as commissioners and as professional leaders, that we put the systems in place to make sure that staffing is appropriate and safe for patients. We need to look, in a variety of ways, at how we do that. The regulators also have a clear role and responsibility. There was some guidance that was published at the end of last week on quality in the system, with very clearly defined roles and responsibilities for all of the key stakeholders in the new NHS. As part of that system, there is a quality surveillance group where we can pull together all of the different elements-CQC, Monitor, the Commissioning Board and so on-so that we can look and review what is going on in organisations, whether they are community ones or hospital ones, to assess what is happening to those patients; what the outcome is looking like; what patient experience is like; what staff are telling us; what the issues are that need to be sorted. I absolutely agree with you that staffing will come into that and is something that they are looking at.

Rosie Cooper: Could you define "urgent" for me? Is that this year or next year? Or could it be maybe never? Come on, this is a real problem. You have Mid Staffordshire, with Francis coming up, and you have CQC telling you that you have dangerous situations in 17 hospitals and you are waiting for a report.

Q58 Mr Sharma: Do you accept that the system is failing at this stage?

Jane Cummings: No, I do not accept the system is failing at this stage. I think-

Mr Sharma: But there are 17 hospitals-

Jane Cummings: Would it be all right, Chair, if I answer Ms Cooper’s comments first? I think CQC will take action very quickly if they think there is an absolute risk to patient care.

Q59 Rosie Cooper: So CQC are now responsible for taking action, not you? It is your job.

Jane Cummings: They are the regulators and responsible for taking action around anything that they assess as being an issue. I have a professional responsibility as the chief nurse in England to make sure that we have good leadership, and we need to make sure that care is appropriate and that patient safety and experience are good. There is action being taken. Those organisations are currently looking at what they need to do and are putting plans in place to do that. In many cases, that has already had an impact. If you want further details, I am very happy to come back to the Committee with an update on what has happened since CQC made that report, if that would be helpful.

Q60 Chair: It would be an interesting followup to Rosie’s question to have a written report to the Committee on what the response has been to the CQC report on the 17 hospitals.

Jane Cummings: I am very happy to give you that.

Q61 Rosie Cooper: With the timeline.

Jane Cummings: I am very happy to give you that response.

Q62 Dr Wollaston: I briefly want to return to a point that the Chair raised about the level of paperwork and duplication that you pointed out, Ms Cummings. I have certainly seen that for myself in the way patients are transferred, say, from hospitals to a community hospital and the paperwork-vast amounts of it-duplicated. Do you have much evidence about how much clinical detail is lost in translation in this process, how many clinical errors are arising as a result of that duplication, not just the waste of time that it involves when staff could be doing other caring roles?

Jane Cummings: I do not. Viv might.

Professor Bennett: We did some work on transforming community services a couple of years ago and looked at transfers of care. We do not have any evidence that things like transcribing errors are very great or that correct information is not passed from one to the other. We did identify an issue of failure to trust assessments by another part of the system and a need to bring together assessments. That would be a single assessment process for the older person, where it is their care plan, their record that moves with them rather than professionally segmented ones. We did identify, through recordkeeping audits, that standards were better in some places than others in terms of legibility, dated entries and so on, and that has led to improvement programmes in the trust; and we did identify the point we made previously that this could be done a lot more effectively and efficiently using new technologies. Fundamentally, we also identified the issue around "Whose record is it?" and it increasingly becoming the individual person’s record of their health, to which we all contribute. That puts the patient or person in the centre of that care. But there is not a particular problem with transcription and transfer.

Q63 Dr Wollaston: In terms of both of your roles as clinical leaders in the profession, would it be possible, rather than waiting for technology to solve this, for there to be leadership from yourselves to say that this is the patient’s record and we do not need these levels of duplication and the sheer waste of time that happens when patients transfer to other parts of the system?

Professor Bennett: We have certainly undertaken some of that work through various processes, both within the health service and within health and social care. Common assessment frameworks for children would be another one. I could not tell you, Dr Wollaston, that there is no duplication. It is better than it was, but too often we still see bundles like that, rather than small ones like that. We are working very hard on clear summary records. I think copying records to patients of interactions with the health service is very helpful. It means that clinicians do write with the clarity and succinctness that sometimes patients can understand, but sometimes they still need some support to do that. So that work around safe transfer of care is in progress. I do believe that it will be enhanced by technology.

Chair: Sarah’s question was around the specific issue of principle, wasn’t it?

Q64 Dr Wollaston: Is it a clear message, leadership coming from the top, saying to nurses working, say, in community hospitals, that it is all right to have the record come from the hospital or from the transfer point and to continue there-that they do not need to start again with vast volumes of unnecessary paperwork? Is that a clear message that is going out to community hospitals?

Professor Bennett: Yes.

Jane Cummings: It is also the very clear message that is going out from the Commissioning Board and our director of patients and information, Tim Kelsey, very clear around the use of electronic records, being paperless and stopping the duplication.

Dr Wollaston: Thank you.

Q65 Rosie Cooper: My father has had a care record every time he has had an episode in care and I have never spotted one where there is not an error in it. Taking Sarah’s point and your point about technology-you say the patient owns the care record-how, if you move to this new technological basis, would the patient or the family know when there is something wrong in there? I’m sorry, Sarah.

Dr Wollaston: No, it is an important point.

Jane Cummings: There is also, obviously, the issue of patients having access to their own records. Clearly, not everybody has access to the internet or electronic means, but certainly a lot of patients are now able to see their records. We have good examples of GPs who share their patient records with them very easily using the internet and other options. So patients can access and look at those records. The issue for us, I think, as we move forward, is to determine how we can make that accessible to everybody, because clearly there are some that would not be able to do it currently.

Q66 Rosie Cooper: Some people do not have computers yet, but a lot of elderly people-such as my father-would not be able to have that so they would never see or know. This is moving forwards for some but not all.

Chair: There is the printout possibility.

Professor Bennett: It is perfectly possible that we could provide hard copies to people and explain that we print things out. They would hopefully be more legible than perhaps we have managed some things in the past. So we have to do both.

Q67 Chair: You did raise the issue of principle, which is absolutely fundamental to this, which is who owns the patient record? Is it the clinician or the patient? When will that be resolved?

Professor Bennett: I do not know, Chair, is the answer to that. It is a very complex issue. Who wants to-

Q68 Chair: Maybe it is outside the scope of this inquiry.

Professor Bennett: Who wants to own their record entirely? Where do people want to place that responsibility? How willing are they to be totally active-

Q69 Chair: I think you have answered. "Not imminently" is the answer probably.

Jane Cummings: It is being discussed as part of the consultation on the NHS Constitution, I understand.

Q70 David Tredinnick: Despite the public emphasis on the 6Cs-care, compassion, competence, communication, courage and commitment-in nursing, and the need for compassion, the majority of the recommendations of the Nursing and Care Quality Forum rely upon local commissioners and providers as well as the Department, the Commissioning Board and regulators to take steps to implement reform. Is this essentially a topdown strategy?

Jane Cummings: No. Clearly, there is an element of that, in the fact that both Viv and I have worked on it, but one of the things that we have been absolutely clear about is our desire to build the strategy with frontline staff. For example, as part of my interview process for this job, I was asked to describe my vision for nursing and midwifery to a group of 50 frontline nurses and midwives. Those frontline nurses and midwives then fed back to the panel what they thought of the candidates, including me. When I described my vision, I got some very positive responses. We then built from that in terms of going out and talking to people up and down the country. We have used facetoface meetings, Twitter, social media, blogs, podcasts and multiple meetings in all sorts of settings where we have talked to patients and patient groups, frontline staff, directors and so on.

We put out a consultation and must have engaged with between 9,000 and 10,000 staff, and we have had masses of response in terms of this strategy. We put it out as a draft first saying, "This is what we think. Tell us what you think. Give us your feedback." We adapted it. A really good example of that is that we originally started off with four Cs. I then added a fifth, which was "courage", and then, as part of some feedback we got using Twitter, we added a sixth. So we actually engaged with frontline nurses, midwives and staff to understand what was important to them and changed and adapted the strategy as we went along. The final strategy that we published in December was the basis of both our thinking but also our engagement with others. So I would not say it is a topdown strategy. I would say it is a strategy that is being led from the top but also built up from the staff working in frontline care.

Professor Bennett: I would simply add that there was concern from some groups of staff that we would be talking about hospitals-again. So we particularly sought out groups of staff like district nurses, school nurses and practice nurses and did some work around what this would look like in those settings, and published it at the same time. That was very well received. We did work around mental health, midwifery and a particular piece of work on dementia. That, again, achieved real buyin from nurses on the ground for whom the overall strategy may feel a bit distant, but, when you are talking about the care given as a district nurse or a school nurse, that matters and they want to get it right.

The area where we state in "Compassion in Practice" we have less developed ways of working with people and that we are working with now is those nurses working in social care and those who work with them. As I said in my introduction, as this sector becomes increasingly important in supporting particularly older people, it seemed to us it was time to develop a vision and strategy that embraced those practitioners, and to work with them to develop that further.

Q71 David Tredinnick: Jane Cummings, you said that originally there were four Cs and you added one, the fifth, "courage"; and then the consultation process came up with the sixth, "commitment". I would like to put it to you that there is one missing, and that is "comprehensive care".

I go back to what I was saying earlier on about ObamaCare and the Patient Protection and Affordable Care Act in America, which is about to come in, and the fact that that Act has no less than seven different sections referring to complementary and alternative medicine, acupuncture, chiropractic and other such disciplines. I want to suggest to you that not only is that coming our way, whether we like it or not because we always, or almost always, adopt policies that have been formulated over there, but there are many nurses out there who are-and you may disagree with that-very frustrated that they are not able to use the skills that they have. You talk about giving professional leadership for nurses and giving good leadership and building a strategy with frontline staff. Many nurses are trained in acupuncture, massage therapy, such as reflexology, tai chi, yoga, meditation and therapeutic touch, and they are not allowed to use it in their hospitals. They are allowed to use it in some hospitals. Will you give a commitment to make it possible for nurses to use these skills in a much wider way in the national health service?

Professor Bennett: I cannot speak for the national health service as it is not my role. In terms of my role in public health-

Q72 David Tredinnick: What about in nursing, in the section where you have responsibility?

Professor Bennett: In terms of my role as lead nurse in Public Health England, we are looking very much at wellbeing. Many of those things are ways of enhancing wellbeing and may be practised by people who are registered in nursing or any other specialty or not registered at all. We would need to understand the evidence around using public money to do that as a specific activity. There are nurses and midwives working who use some elements of that-for example, midwives who use massage with aromatherapy oils for pain relief in labour. So there is some of that integration already taking place. We also have to be mindful that, with people holding their own health and care budgets, they may choose to purchase some of this kind of care as part of managing their usually ongoing condition, if they are having those budgets, and to look at our responsibilities in making sure that it is going to be delivered to them in a safe and wellregulated way. So there are a number of ways in which we are approaching, I think you called it, "integrative medicine" within the health and care system.

Jane Cummings: I would support that. It is already in place in some areas, as Viv has described. The issue is thinking through what is the right care package or treatment for the individual patient and then who is best placed to provide that care. That is probably the way to look at it rather than decide whether it is the role of a nurse, a therapist or a doctor. It is about looking at what is the need of the individual patient, what care they can have-or what should they have-and then who is best placed to deliver that care.

Q73 David Tredinnick: My point is slightly different. I am suggesting to you that you have nurses out there with skills, and you should be putting out guidance saying that if they have these competencies-and they are safely and properly qualified, obviously-they should be able to use them. At the moment, there is quite a lot of resistance in hospitals and a lot of nurses are finding it very frustrating.

Professor Bennett: I do not have evidence of that, but clearly you do. What we have is increasing use of volunteers providing some of that under the support of nurses, so Kissing it Better-

Jane Cummings: That is a really good example.

Professor Bennett: Their website is a really good example. For example, they have sought to bring community and hospital together, or community and care home together, by using some of these alternative approaches, whether it is pets for health, hand massage from the local beauty students or actual aromatherapy oils in use. That has been therapeutic for individual patients but a really important thing for hospitals, particularly, to take down some of the barriers around, "Actually, we can safely welcome these people in; we can make sure that whoever is supervising them has had the appropriate CRB checks; we can deal with unnecessary rules that have concerned us before, and we can give that patient or person in a care home a much more rounded experience." That has been a very helpful step forward, the volunteers and the nurses working together to deliver that care.

Jane Cummings: Pet therapy is a very good example of that.

Professor Bennett: It is a very good example.

Q74 Andrew George: I want to come back to the issue of resource and staffing levels. In your own work, you are suggesting that it is a much more complex issue and, therefore, establishing skill mix in particular settings is not particularly aided by establishing either guidelines or benchmarks, let alone mandated registered nurse staffing levels. But, for example, in Australia, where they have it, if you were there visiting, what would you be saying to them to point out how incompetent that particular approach is?

Jane Cummings: I would not say it is incompetent. The important thing is that there is guidance and there are tools that can be used to determine staffing levels. A good example of that is the "Safer Nursing Care" tool, which was designed and developed by two very experienced nurse directors. That has been research-based; it is evidence-based; and it is now in practice across significant parts of the country. It assesses the individual needs of patients over a period of time and then works out what skill and numbers of staff they need. So there is plenty of guidance and there are tools that people can use.

There are also suggestions from people like the Royal College of Nursing, the Royal College of Midwives and others around staffing levels. So, rather than mandating something at a national level, our view is that people should use the evidence that is there and apply it to their local circumstances. The risk with mandating something is that you miss the point about the flexibility-the differing needs of different organisations. You could say a medical ward or a surgical ward needs x or y nursing staff, but that might fail to notice that one medical ward has a very different case mix than another. For me, it is about using evidence, being absolutely clear with the staff why you have determined the staffing levels, making sure that you assess the impact of that and looking at what happens to patients. You measure patient outcome. We could look at things like patient falls and pressure ulcers. We could look at patient experience and at staff experience. If you look at all of those things together, triangulate them and link them to staffing and the evidence, that is the way to get the best approach to determining your staffing. Our recommendation is that that is published at least twice a year so that organisations can not only describe to their patients and the public what they are doing but also to their staff. Then I think we will be in a better position.

Q75 Andrew George: So it is a much more nuanced approach and certainly mandating, or indeed national benchmarking, does not particularly help. But in circumstances where professional registered nurses come on to a ward and believe that staffing levels are dangerously low and they report that, as they come on duty, on their Datex form and then that is perpetually ignored, the impression is given, at least, that, where this is reported, those nurses fear the consequence of raising issues in terms of both their own career and the treatment of their seniors. It was suggested by Barbara that, indeed, nursing directors should be taking this on board, but would you agree that they might be conflicted because nursing directors are also responsible for helping the trusts achieve their budget targets, their discharge targets and other targets? Do you think all the tools are in place to ensure that that level of sensitivity is there to make sure that staffing levels are indeed adequate?

Jane Cummings: Yes, they should be. Any director has a corporate responsibility as well as an individual professional responsibility, but I would say that safe staffing is as much a responsibility of the finance director and the chief executive as it is the nurse director. It is everybody’s responsibility.

Q76 Andrew George: But they are conflicted. How do they overcome that?

Jane Cummings: The fundamental issue-the thing that we need to put first and the thing that many organisations put first-is patients, patient care and patient outcome. There will be some people who will say, "That doesn’t happen in my organisation", but it should. "Care is our business" is what we have called the 6Cs and the strategy "Compassion in Practice". It is "Care is our business". I know of many organisations where finance directors will report on quality issues to their board. I also know of organisations where finance directors will be absolutely happy to support nurses and medical directors look at staffing levels. So, yes, some people may feel slightly conflicted, but, fundamentally, if we put patients first, that is the key area. There are tools, there is guidance and there is support to enable those staff to do it.

As to your comment earlier about frontline nurses being able to step up and say they have an issue, for me, ward sisters or community team leaders are the ones that really understand what is happening in their areas and they are the ones that should be able to say, "This is where we are. These are the issues we have and we need help to sort the problems in terms of staffing."

Q77 Andrew George: Even though, by implication, they are being criticised.

Jane Cummings: You mean, they will be criticised-

Q78 Andrew George:-by their frontline staff, by saying, "You haven’t given us sufficient staff on the ward."

Jane Cummings: Yes, but at the end of day it is around the culture. I have been to organisations all over the country and I talk to staff probably on a weekly basis. In a significant number of organisations I go to, staff are incredibly open, they are very transparent and very clear about what is happening in their organisations: they publicise on a board and describe what is happening; they tell the patients what is happening-for example, how many falls there have been; they talk openly about the difficulties they may have had in staffing, what they have done about it and how, in many cases, they have improved it. So, yes, I think there are some issues and there will be some organisations that struggle, but we are certainly shifting the focus in terms of quality and having the appropriateness. There is definitely recognition that that is important.

Professor Bennett: I was going to add to that. It clearly is very important and it is an important issue beyond the acute hospital as well. We have to make sure that the work we are doing includes mental health hospitals, learning disability facilities and community teams. Currently, we are very concerned to look at district nursing numbers because we have more old people, and in the care sector the statements we have made about directors of nursing apply to care home managers, who can often be raising these issues with their employer in very small organisations. So it is something we take incredibly seriously right across the piece, although the focus may at the moment be on hospitals.

Q79 Andrew George: Finally, if I may, the issue was raised in the previous session in relation to the attitude of nurses and their perhaps not respecting dignity, not being compassionate, not being sufficiently considerate. It seems to me that in your 6Cs, there is a potential-and certainly the nurses I speak to tell me in terms of the challenges in their own profession there seems to be a potential-conflict between the second C, "compassion", and the third C, "competence". It is clearly quite possible to be both at the same time, but what nurses often say is-I am not putting this very well-what if a patient has a choice between a competent professional nurse and someone who is perhaps less competent but more compassionate? Sometimes in order to be professional, you need to be dispassionate as well, and sometimes the issue of getting too involved with the patient can deflect a nurse away from being able to make a dispassionate professional judgment. You are both experienced nurses. Is there something there? Is there an issue that needs to be, if you like, recognised, for the highly trained registered professional nurses?

Jane Cummings: You can absolutely be both. You can be a highly competent, experienced, professional nurse and still be compassionate.

Andrew George: Of course, yes.

Q80 Chair: And dispassionate at the same time.

Jane Cummings: Absolutely. Nursing and midwifery is a very emotionally draining job. It is hard work. It is physically hard and it is emotionally hard. That is something that we comment on and reflect in the strategy. There is something about how we look after staff and how we give them the time and the space when necessary to take a step back and have a bit of breathing space, to then go back in. If you are dealing with very complex things or are very busy-if you are in an emergency department, say, and my background is in emergency care, so I spent many years working on the frontline-day in day out, very demanding, it can be quite difficult to remain compassionate all the time. However, we have lots of examples of nurses and new student nurses who are incredibly compassionate and able to deal with very complex things on a daytoday basis. Nurses that work in palliative care, oncology, cancer care, are able to do that day in day out, and that can be incredibly difficult when you are doing it every day. Nurses up and down the country are still able to do it, so I do not think we should differentiate between being competent and compassionate. Actually, the nurses that I speak to day in day out and the student nurses that we have working with us as ambassadors of the 6Cs are absolutely committed to being both competent and compassionate.

Professor Bennett: I think it is a really-

Chair: Andrew, can we move on? Sarah has been waiting, as have Barbara and Rosie.

Q81 Dr Wollaston: One of my points has already been covered, but there was one other point I wanted to raise, which goes back to the point when you touched on having a greater role for volunteers. Do you feel also there is a greater role for families to play? I have had people contact me concerned about visiting hours, for example, in hospitals and, as they see it, overly restricted visiting hours, excluding families at meal times just at the time when they make the point that they could be there to help nursing staff. Do you have a view on the future of involving families more in volunteering?

Professor Bennett: I think it is a very interesting issue, particularly for older people. We have older people who tell us that they felt excluded and that they would very much have welcomed being the extra pair of hands at meal times as they particularly know how the person they look after all the time likes to be helped with their food or likes to have their cup of tea. We have other times when people say, "Frankly, I am exhausted. I cannot do this any more. I need to step away while this person has the procedure they need to have or the respite care in a home or a hospital." So I think that it is very individual. It is unfortunate when we make judgments that say either way is right or wrong. We do not, for example, think it is wrong that families provide a lot of care for children when they are in hospital, but we seem to think somehow that it is wrong that people want to carry on their caring for adults, particularly in hospital, actually. I think it happens less in the care home sector. I do think that we should respect the views of the patient, where they are able to make them, and the carer, and, where they want to provide that help, we should find ways of letting them.

Q82 Dr Wollaston: So we should have open visiting available on adult wards and particularly in elderly care if people want it.

Professor Bennett: Where it is the right thing, yes, we should. That is my view.

Q83 Barbara Keeley: I want to come back briefly to the question of ratios. Then I will lead into another question. It struck me while you were responding to Andrew George that we do have ratios in other areas of care. We do not allow a nursery or a setting for looking after children-particularly young children-to just operate on any basis that it wants to, particularly not to operate on a basis that would be considered dangerous to the safety and welfare of the children there. In a situation where we have lost 7,000 nurses-and the other things you talked about are very important-and, frankly, we have had reports here and seen examples of older people that are in hospital being left soiled and nurses not even noticing, we heard earlier, when glasses were taken away by domestics, not answering buzzers and not helping with pain relief, I persist in believing that this question of ratios and adequate staffing levels is one of the most important things. Comment further if you want to on that, but, if you cannot trust and tell a hospital to have a safer staffing level, then I think we have an issue.

This strategy is an attempt to alter systems and approaches to care. You have talked about needing cultural change, and clearly that is in NHS organisations and the independent social care providers. In many ways, it should be easier within NHS organisations, but it does not seem to be because you do not have the levers to tell a trust what it must do in terms of its nursing levels. So, in fact, if you cannot, in your roles, influence NHS hospitals to do the right thing, to have safe levels of care, how can you then influence thousands of social care providers to do that? In a locality that had one of these hospitals with dangerously low levels of nursing care, how could you influence the social care providers that surrounded that hospital, given that the hospital trust is not even leading by example? This is the approach, this is the strategy, but how do you do it when we cannot even do it in the NHS?

Professor Bennett: As I said earlier, we have to find different ways in social care for the cultural issue that you were talking about and actually working through different ways. In terms of the staffing, again the answer is that it is a regulated system and CQC are responsible for the staffing. They have very clear guidance around the regulation of staffing in social care and the home care manager is responsible for ensuring that staffing is in place. CQC can and do issue notices and withdraw licences where that staffing is not in place in social care. Again, the answer is that the mechanism around staffing levels is through the regulator. There is a wider issue-

Q84 Barbara Keeley: Should the same thing happen in hospitals then? We talk about integration, bringing these parts together. Should it be the case, if we are willing to do that, if we are willing to take that action with a social care provider, that we could do the same with a hospital trust and say, "You are not operating at a safe level of care. We are going to close you down this weekend"? It is a horrendous thought, but is that the way to deal with it?

Jane Cummings: CQC have the statutory responsibility and legal ability to do that.

Q85 Barbara Keeley: As chief nursing officer, do you think they should?

Jane Cummings: You would have to look at what the risks would be. For example, if CQC made a decision that something was unsafe or it could potentially shut, one of the things we would need to look at is what the implication is for that local population. For example, can the patients that need care be easily cared for somewhere else? It is exactly the same thing as if you closed a residential or a nursing home. Those patients then need to be transferred. You have to think about the risks overall. Or can you put additional support, intervention or help into the organisation that you are concerned about in order to make sure that they do provide a safe staffing rather than close it? Sometimes closing is a bigger risk to the health of the population than it would be to put intervention and support in.

Q86 Barbara Keeley: It is likely to be the same with social care providers. If you had a specialist home for people with dementia, there is not likely to be another one locally. Moving people who are in the later stages of life with something like dementia is liable to kill them anyway because moves are very dangerous for people like that. Are we effectively saying that, whatever strategy and vision we have, we cannot do this thing about safe staffing levels? We cannot do it because we cannot take the risk that closing a hospital or closing a specialist dementia facility would be more damaging than limping along with the situation as it is.

Professor Bennett: What is not acceptable is to leave the situation as it is.

Jane Cummings: No, it cannot stay as it is.

Professor Bennett: So there is a choice. You either take some action with the provider to make it safe and make it safe now and with a plan to make it safe in a sustainable way, or you have to remove the patient or resident to a place that is safe. Either of those may be done.

Q87 Chair: If the only issue is the ratio, then you can get that right by limiting admissions-

Jane Cummings: Exactly. There are other actions you can take.

Chair:-until you have the staffing right. You do not need to close the provider.

Professor Bennett: And, of course, as Jane said, it is not always an issue of simply numbers. It is an issue of skill as well.

Q88 Chair: That is why I said "if the only issue is the ratio".

Professor Bennett: Yes.

Jane Cummings: Is it possible for me to respond very briefly to a comment that Ms Keeley was making around pain, nutrition and toileting, because I think it is a very valid comment and one that certainly has been reported a lot, and we heard colleagues earlier talking about it?

I think that the nurse rounds that have been put in place over the last 12 months or so have made a significant difference. I have been to many organisations, hospitals and wards where I have watched them, seen them and talked to staff that have done them and to patients. Patients by and large really like them-though in some mental health organisations it does not work as well-and feel safe. They know they have people coming. The evidence is that call bells do not go off as often because patients know they are going to get help. They are given plenty of opportunity to drink, to go to the toilet or to be asked if they have any pain. Across England now it is beginning to have a significant impact. In a recent survey we did, 100 hospitals replied and I think something like 91% or 92% of them had either rolled it out in every ward or were going to. So we are beginning to see a significant amount of feedback about the very positive impact of what, in many ways, people will say is a very simple thing to do. It is making a big difference, and we need to build on that and make sure that it is spread more widely.

Q89 Barbara Keeley: Would you expect that the numbers of reports with alarming stories in them produced by the Patients Association and other bodies will go down?

Jane Cummings: I would very much hope so. In the organisations that have those rounds in place, I would very much hope so.

Q90 Barbara Keeley: Are you going to monitor that?

Jane Cummings: We are monitoring how many wards are using rounding or whatever it is called-there are a variety of different names-and we are looking at that and monitoring it.

Q91 Barbara Keeley: My final point was going back to this question of compassionate values and valuebased recruitment. There is the question about how compassion can be assessed in recruitment. Are you looking to something like role playing exercises where you can, during recruitment, assess that? It obviously hasn’t to be prone to just an answer to a question really. You are going to have to have some other way of assessing it.

Jane Cummings: Yes. One of the first things I did when I was appointed was a survey of every university in England. We asked them to describe what they did in terms of their recruitment of nurses, student nurses and midwives. We asked them how they recruited, how they assessed for values, behaviour and what they did throughout their training to ensure that that was going on. To be honest, we had quite a mixed response. There were some that had a significant amount of work and others that were not doing very much at all.

What we are doing at the moment is working with Health Education England and looking at every university recruiting. We are also assessing the different techniques that people use. In Great Ormond Street hospital, for example, they work with their local university and they have scenario testing where they give potential students scenarios and ask them how they would respond in order to test out how they would react in different circumstances. Some of the evidence around that is that it is having a significant impact on both students actually understanding whether nursing is a job for them but also enabling them to look at what they do.

So we are assessing what the best practice is, and we will be looking at implementing that across all of the universities, in the same way that they are embedding 6Cs in undergraduate education now. I got tweeted not long ago by a nurse, who said, "First week as a student nurse, first week in my university and have already been taught about the 6Cs." I was very pleased, as you can imagine.

Professor Bennett: We also have some experience to build on in terms of the health visitor development programme, where we were trying to recruit very rapidly students to meet the Government’s commitment to the growth of health visiting. There was extreme concern from the profession and from parents’ organisations that we would somehow dumb down the entry, that new health visitors would not have either the competence or the compassion to work in longterm relationships with very troubled families. We have already rolled out making sure that people are tested for those values and attributes before they can move in from nursing or midwifery to health visiting, so we have some lessons to draw on.

Q92 Rosie Cooper: I would like to try and ask a question that will almost bring together both the panels we have heard this morning, joining it up with the first panel. Reports on poor nursing practice from patients and families frequently relate to continence care. Mid Staffordshire and many of the Patients Association reports feature it. It results in many patients being left in soiled, wet beds or clothing, and that has a massive impact on patient dignity. Correct continence care should be a basic expectation for patients. In 2009-three years ago, I must admit-a survey of 1,000 qualified nurses found that one third of the respondents received no education about caring for incontinent patients during their undergraduate training programme and 53% reported having no continence training after registration.

You are both leaders in the profession and are telling us how things have improved. We are still hearing tales about the situation surrounding incontinence. Is enough time dedicated to educating pre-registration nurses to manage continence problems and provide dignified care, are there sufficient numbers of specialist advisers in acute hospitals, and what plans are there to improve continence care for patients in hospital settings? I will localise it there because we could go on in a really big way if we move on to other areas. But this is probably a core training area that would make care of the elderly so much better.

Professor Bennett: I agree with you that it is so important and it is-

Jane Cummings: Yes, it is absolutely important.

Professor Bennett: If we imagine it for ourselves, it would be one of the most humiliating things that would happen to us and we should keep that thought at the heart of our practice. I think we have to do a lot better in managing continence rather than coping with incontinence. Certainly part of the nurse training, post-registration, is around managing continence, enabling people to be as continent as they can be, whether that is reminders for people with dementia or exercises for people with a prolapse, frankly. It is really important that we focus on those areas as well, and within the acute hospital we are very mindful of that. I will pass to Jane to answer the hospital focus you wanted.

Q93 Rosie Cooper: But has it improved? 53% reported having no continence training after registration.

Jane Cummings: I do not know the answer to that question so I would have to go away and look. I can also ask the question about what happens in undergraduate training because I do not have that level of detail with me.

Q94 Rosie Cooper: Great, but you can see that this is core to where we are going.

Jane Cummings: I absolutely agree with you. It is vitally important.

Q95 Rosie Cooper: You have just described having been out there talking to students in all sorts of areas and you have described it as basic.

Jane Cummings: It is absolutely.

Q96 Rosie Cooper: But you do not know the answer.

Jane Cummings: I do not know the detail of what they do in part of their undergraduate training.

Q97 Rosie Cooper: Forgive me, but all I am really trying to demonstrate is that, yes, there is a real problem, it joins the two panels together and yet it is not high up enough on your agenda for you to have actually done a bit more about it. But I would be grateful for any information in answer those questions.

Jane Cummings: We have done lots on how to deal with it in hospitals. The detail about the education I do not know, but I will come back to you on it.

Rosie Cooper: I really fear that a lot of what I have heard today is about what we "should" do-"we should be", "the frontline should be"-and, if I were to leave you with a comment from me, it is not about what you should be doing but what you are actually doing, what you are doing day to day to make this change. You have described, in theory, about trying to join up the NHS, with patient-centred records. When you drill down about a difficulty or a problem, what you describe is a fragmented system of delivery: "It’s an FT hospital", "It’s a this", "It’s a that", and "People locally should be responsible." Yet everybody is looking to you as the chief nurse and the Department of Health. It needs to join up.

Chair: We are in danger of getting postscripts from everybody. Andrew George would like one as well and then perhaps we will have one from the witnesses.

Q98 Andrew George: It is not a postscript or a comment. It is a genuine question. On the basis of training, in terms of your role, it is my understanding that nurses, when they complete their nurse training, are still in either all or most cases-and I may have got this wrong-not trained in taking blood or in administering IV at that point and yet should be wardready in fact to fulfil both those functions on their first day at work. If indeed that is the case, and I have been told that it is the case, is there an issue from your point of view of making sure that-and I mean not just continence training-the whole kind of training programme itself is reviewed, and is that part of your function, your role? That is for either of you, but especially you, Jane.

Jane Cummings: There has been a review of training fairly recently. In fact, the NMC-the Nursing and Midwifery Council-have been going through quite a lot of just checking out what is happening in all of the universities up and down the country. The point you are making is around the role that nurses take as they develop. I do not necessarily think that a nurse coming out of training and going into a ward or a community absolutely needs to be able to give IVs and take blood on day one. But I do think that that is part of their support and development over the first six to 12 months. As a newly qualified, newly registered nurse, you have to get used to working as a qualified nurse. There is a very big difference when you answer the phone and say "Staff nurse" and when somebody comes to talk to you as a nurse in a uniform, qualified. So I think they need to adapt; they need to work in the environment that they are working in and to undertake lots of different additional skills and training as they go through.

Many organisations have very good preceptorship programmes, which include support and development for newly registered nurses, but also skills development as they go through. I was at Imperial, Hammersmith hospital, recently where they were showing me what they were doing with their newly qualified staff. There are very clear programmes of development and support. So I think that is probably quite important.

Q99 Chair: I get the sense that a number of people would be surprised that you can do a degree in nursing but you are not qualified to do a blood test when you become a qualified nurse with a degree.

Jane Cummings: Clearly, you can do blood tests and some of them may well be able to do it, but not everybody is going to come out and immediately go straight into giving intravenous drugs, for example. Some will, but not everybody.

Professor Bennett: It is a really important point, Chair, that people doing a degree in nursing are still doing at least 50% of their time in clinical practice, learning a range of nursing skills with a range of procedures that may need to be done, whether or not that is taking blood. It is very important when they choose their first place of work that they have the skills that they present with assessed and, if they have not given an intravenous drug, that they are properly supervised in that period that we call preceptorship to do it. Some of the tasks will be available to them and some not. Is it possible to make one last point?

Chair: Yes.

Professor Bennett: I wanted to respond to your point about fragmentation. We absolutely believed that it was right to do this together because we have many more organisations in the new health and care system and many nurse leaders. From our point of view, we need to work across the system to try to drive some of this culture change that we need to see. That is why we have done this strategy jointly. That is why we have tried to build those professional bridges that we can build across different parts of the new system and why we are so passionate about joining up public health, the NHS and social care. As a profession we try to work across and to do the integration that we can do in the new system.

Barbara Keeley: There have obviously been some exchanges in this session, but the key thing I feel-and I think a few of us might feel-is that we want to see that you have got the levers. I do not think vision documents and some of the processes you talk about give you the levers. If you don’t have the levers, then we are worried about what is happening to nursing. That is how I feel about it.

Rosie Cooper: There is an old Liverpool expression where a docker-I understand, anyway-refers to his wife as the "shudda woman": "You shudda done this; you shudda done that", and I am really tired of hearing what people should do. I want to know that they are doing it.

Q100 Chair: We will have the final word from the chief nursing officer for England.

Jane Cummings: The key thing is that this document that we published in December has a series of actions. I entirely understand some of the-what could be described as-cynicism, I suppose, around, "Is this just another set of words and you are going to give us a load of platitudes and you are not going to do anything?" Actually, we were both very passionate about the fact that there is no point in us giving a load of lovely words if we do not do something. So the vision is underpinned by six very clear areas of action. We have committed in the document to having a detailed action plan with who is going to do what and by when agreed by the end of March. We may deliver that slightly earlier, but we will have that by the end of March. That will set out the actions that we will take as a Commissioning Board, as the Department of Health, in Public Health England and in Health Education England, to name just a few.

It will also talk about what we expect local organisations to do. We are going to use something that we have called the NHS Change Model, which is something that has been developed that identifies a series of eight areas of action in order to deliver largescale change. It is evidence-based, and included in that is using system levers and incentives to be able to deliver. That is an absolutely critical part of our ability to make this work, as well as leadership, clear performance management around the things that we said we were going to do-we are making sure that we do it-taking people with us and mobilising for change, to name just a few.

Both Viv and I are absolutely passionate that we really do want to make a difference. I have been a nurse for over 30 years. I love my job. I still volunteer with a children’s charity and work as a nurse. I love what I do. It is a brilliant career and we want to make sure that our patients get the care that they deserve.

Chair: On that note, thank you very much.