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It is important in creating organisational change to meet the needs of patients and ensure that patients are involved in planning in a very real way, not just a token involvement but in a participative way. I recently witnessed that by attending the opening of the Royal Alexander Children's Hospital in Brighton, the planning of which I was privileged to start several years ago.

Children and young people were involved in the planning and formed a young people’s board. They took a central part in the planning and delivery of the operational policies. That was not just a token involvement but a real participation, together with representatives of parents and staff. The board met in the presence of the chief executive, but a young person took the chair—each taking it in turn. There were proper agendas, minutes and briefing papers. For example, they designed the cubicle curtains, interactive sculptures and a new time capsule. They also created a new Alex website with a gallery on the web, where young people could show the artwork that they had produced while they were patients. They also developed a play philosophy in partnership with the Alexander staff, which has now been adopted, alongside some of the patient care pathways. Several awards for that innovative approach have been given and the media attention has raised the profile of the trust. That shows a genuine commitment to involve children and young people in their new hospital.

The provision of patient-focused care is possible for every specialty from obstetrics through all the acute and chronic diseases, including end-of-life care,

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mental health, and learning disabilities, but it requires special skills for engaging patients in a real way, rather than through a token consultation. I declare an interest: as part of my role as a regional nursing officer, I managed the change of the closure of two large institutions, each having more than 1,000 patients with learning disabilities, and transferring them to community care, each having an individual programme following assessment. The whole exercise took 10 years and much patience, involving patients and their relatives, training staff and involving the local authorities, especially the directors of social services, in transferring the services to the community. It was costly, but that service is now proving to be well managed by social care with health services giving support to meet healthcare needs.

The noble Lord, Lord Darzi, is spending much time listening to staff and local people in his continuing review of the NHS, and I hope that the innovative ways of involving patients in the design of the new healthcare system will take a hold and that various models of good practice will be delivered so that the quality of care can be raised cost-effectively and efficiently. The management of such changes calls for a change in culture. For some healthcare professionals, the involvement of patients poses a threat. There is no need for this if there is someone to champion change.

wrote Florence Nightingale in 1883. It may seem even stranger that Her Majesty’s Government propose to introduce in the new Session legislation to create a stronger health and social care regulator with a remit to ensure a clean and safer service and a high quality of care, but the need has sadly been made evident by the two recent Healthcare Commission reports into hospital-acquired infection. Again, I declare an interest as a resident living nine miles from Tunbridge Wells and seven miles from Maidstone, and I am very aware of the great distress caused to patients, to relatives and indeed to staff and the community as a whole.

Having studied the reports very carefully, I see that there is indeed a need for accountability and authority to be strengthened from the point of delivery of care to the board, with 80 per cent of care being delivered by nurses. The urgent need is to ensure that the ward sister or unit manager has the authority and accountability to deliver safe care, supported by clinical teachers from the universities to assist in ensuring that theory correlates with practice. The Nursing and Midwifery Council requires 50 per cent of training programmes to be spent in the clinical area. However, with the pressures caused by an overheated system, with bed occupancy often in excess of 95 per cent or more, students very often lack supervision. This requires a review of workforce planning, taking account of patient pathways and the numbers required to be trained and to deliver care, by the Strategic Health Authority in liaison with the universities. The retraining of sisters at ward level is essential if infection is to be prevented and the environment managed, as is providing clinical teachers,

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possibly with joint appointments between the universities and the NHS trusts, as has already happened in some cases.

None of this can be effective unless there is an officer accountable at board level for the delivery of care, and the board must be as committed to the safe delivery of care as it is to balancing the books. This requires a training programme for all board members and will be successful only if there is a change in culture. It is interesting to note that the only NHS trust to have no MRSA for two years was the Royal Marsden, where controlling infection is a high priority and where at board level there is an officer accountable for nursing, catering and cleaning.

I have concentrated on hospitals in the time available to me, but the same principles apply to community care. There must be accountability from the point of delivery of care through to the board, and there is a need to review the workforce planning arrangements between the SHAs, taking account of patient care pathways and the number of training places to be commissioned with the universities both at pre-registrations and post-registrations levels, with the inclusion of more joint appointments of clinical lecturers supervising the delivery of care.

It must be a false economy to cut training budgets, which the noble Earl, Lord Howe, mentioned. The absence of accurate workforce plans is an even more false economy, as is cutting advanced practitioners and specialist nurses who provide effective care. I look forward to taking part in various debates on the new Bills.

1.44 pm

Lord Pilkington of Oxenford: My Lords, I shall consider the proposed reform of examinations over the next decade, in particular the effect on vocational education. The problem is that this country has mishandled vocational education for well over a century. In 1902, the state created its own grammar schools. An examination system existed to sustain them, but even then vocational education was neglected. There was a reliance on very ancient apprenticeships, and the great technical schools of Victorian England, which were created by the whisky tax, were deliberately and very badly run down.

By 1945, reform was desperately needed. In essence, the English state decided then, as it has continued to do, that the best way to improve vocational education and to give it prestige was to make it parasitic, or, if you like, to subsume it into the academic pattern, both in institutions and examinations. This was the thinking behind the comprehensive schools supported by both major political parties. I remember the cry that brain surgeons and plumbers would all be educated in the same institutions. The same argument was advanced when my party decided to amalgamate O-levels and CSEs in the 1980s. The idea ran like a seamless web through the whole system. Furthermore, the system of vocational examinations introduced from 1986 onwards failed to achieve a clear shape of vocational qualifications that were respected by the whole community. I should add that neither political party was prepared to take on industry and ask it to pay something and provide

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personnel to help to supervise and arrange vocational education. That fact rises above politics.

Our continental neighbours faced exactly the same problem in 1945. Vocational qualifications were not valued and were seen as inferior to academic ones. However, they followed a different pattern. They created freestanding vocational schools, supported by generally recognised vocational examinations. In many cases, often under pressure from the state, industry had to pay something towards this and provide examiners for the courses. This was most successful in Germany, although it is true that Germany had a long interest in vocational education—Sunday schools in Saxony gave vocational education in the 1720s. Germany created its famous vocational schools—Berufsschulen—which are highly respected and combine traditional education with training for a trade. Austria does the same. In Austria, about 50 per cent of the relevant age group goes to vocational schools. The university system there examines people in detail right the way through, and many people drop out of the courses, but it is not such a disaster because they move on to vocational diplomas and then have a trade and respect and can earn money. Holland, Switzerland, and France to a degree, follow the same system.

Although the noble Lord, Lord Adonis, is absent, I pay him the compliment that he has a genuine interest in academic excellence. However, I stay here on a Thursday afternoon to make this speech and to urge him and his colleagues to consider the continental experience. Merely trying to create an adjunct to A-levels will not work. To gain respect, vocational education has to stand in its own right, and have examinations that are recognised right through society. The Government have to be prepared to act with great courage and say to industry, “You’ve got to pay something towards this and provide personnel for the exams”. If they do not do that, it will be another in a long history of disasters that began in 1902 and ran through to 1945. I remember the late Keith Joseph saying to me that he made a profound mistake in the 1980s. Let us hope that the noble Lord, Lord Adonis, avoids that.

1.50 pm

The Lord Bishop of Ripon and Leeds: My Lords, I give a wholehearted welcome from these Benches to the Government’s commitment in the proposed Education and Skills Bill to move towards the participation of all young people in education and training up to the age of 18 and to the ambition to make the country a world leader in skills, as expressed by the Minister in his opening speech.

Churches have long been committed to a full and engaging educational experience up to the age of 18. We welcome the opportunity to work with the Government to meet those aims in schools and FE and HE institutions. It needs to be a commitment to an education that equips for life as well as providing skills for work. Young people should have, in the words of the Green Paper for the Education and Skills Bill, personal capabilities, resilience, interpersonal skills and attitudes—that is, people who are becoming whole and rounded adults.



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We welcome the emphasis on compliance within the Bill—on compliance from employers as well as from young people. We recognise that additional measures may be needed in order to achieve that compliance. As far as young people are concerned, the need is to make that provision as attractive as possible. Colleges must have as much richness, variety and depth of provision as schools have now. In schools, there is already the welcome availability, which could be developed further, of vocational courses and an increase in the number of 14 to 16 year-olds taking skills courses either in school itself or through local colleges. In school sixth forms, there is the valuable contribution of spiritual, moral and social development to the development of the whole person. This Bill will provide opportunities for those from deprived backgrounds to achieve greater status and recognition because of the higher status that should be accorded to skills education from 16 to 19.

I welcome the apprenticeships emphasis, Train to Gain and employer-based training in general. I echo the concern expressed by the noble Lord, Lord Pilkington, for the new vocational diplomas and the way in which they actually work, both in terms of being credible to employers and in providing an opportunity for the personal development of young people, especially those with the greatest need.

My own education between the ages of 16 and 19 appeared to have no interest whatever except in academic attainment and possibly sport. It would have been good had that education had some sort of emphasis on skills. Then, as now, however, there was little emphasis on what ought to be a strong core of our learning—on citizenship, spiritual and moral development, in order that we can develop a sense of meaning and purpose in our lives. This Bill and this moment provide an opportunity to do that at a crucial point in the life of our society.

We talk a lot about community cohesion. We do a lot of work in Leeds, for example, to enhance good community relationships and provide support for families. All of that needs to be expressed within the 16 to 19 curriculum, and it needs to be properly funded. The noble Baroness, Lady Barker, spoke earlier about the need for proper funding for these among other developments. That hangs like a sword of Damocles over so much that is exciting in all the proposals that we debate today.

I will take an example from the proposals for children in care in the place of residential family assessment centres and the removal last month of financial support for residential assessments despite a universal recognition of their value. The argument that was used was that it was the responsibility of local authorities. In many cases, local authorities believe that such assessments, however beneficial they may be to the families concerned, are simply too expensive. In a range of areas concerned with children and young people, local authorities must be properly funded if the aims of the proposals are to be achieved and if our society is to benefit from them.

I hope that the Government, through the Education and Skills Bill, will take the opportunity to correct the anomaly over the entitlement to provision

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for spiritual, moral, social and cultural development, which 16 to 19 year-olds have in schools but not in colleges. That is an anomaly of the Education Acts 1944 and 1968 which did not cover FE colleges at a time when most FE students were on day release. In the Further Education and Training Bill of the past Session, the Government did not feel that it was appropriate to extend that entitlement to FE students. But now we have a broad vision in this proposed legislation which is quite different from the more technical concerns of the Further Education and Training Bill. It would be extraordinary to concentrate on specific skills and not to take account of those moral and social values that need to be at the heart of our community culture and therefore of our education system.

Young people have so much to contribute to that culture and that can be helped only if we are prepared to look to the provision of education in moral and social matters within the work of the FE colleges. There also needs to be significantly more emphasis on that group of subjects within teacher training and the encouragement within FE of those particular parts of our being.

This entitlement is about equality of esteem and value for all students up to the age of 18, whatever the appropriate pathway for their education. It is about supporting colleges in ensuring that students have the opportunity to explore and challenge their own faith backgrounds, their own particular faiths or their own lack of faith. The lack of availability of effective provision for students’ spiritual, moral and social development on college campuses can leave them vulnerable to other sometimes extremist influences. This can then help to destroy the social cohesion for which we are all trying to work. The overall provision in colleges needs to provide the opportunity to celebrate and value faith and to explore social development within its overall provision. It cannot simply be left as an optional extra. Values appropriate to our multi-faith society need to be inculcated in the overall provision made through these groundbreaking proposals.

The churches have a long history of engagement with skills education. We are immensely supportive of the aims of these proposals and I look forward to a fruitful discussion of the ways in which this can be a moment which is seized in the cohesion and coherence of our whole society through proper provision and support for those in the 16 to 19 age group.

2 pm

Baroness Murphy: My Lords, I want to talk not so much about what is in the legislative programme on health—which is fine as far as it goes, and we shall have ample opportunity to talk about it—but about what I see as being missed out: legislative measures to support existing NHS reforms. The recent tragedy at Maidstone and Tunbridge Wells hospitals, to which my noble friend Lady Emerton alluded, where more than 90 people died of C. difficile infections, is no more than the visible tip of an iceberg of many NHS

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hospitals where we would not want our relatives to be cared for and where the standard of care is not only unacceptable but seemingly resistant to change. In my view, this is the inevitable outcome of 60 years of direct central management of the NHS from Whitehall.

Some noble Lords will be thinking, “Rubbish”, and that bad managers, second-rate clinicians and incompetent boards are to blame. As someone who has worked as a hospital consultant, a chief executive and a trust chair and who is now on the board of Monitor, the foundation trust regulator, I have direct experience of dealing over many years with the constricting chains of Department of Health management, where boards are regarded at best as largely irrelevant and at worst as a positive nuisance; where chief executives spend up to a quarter or more of their time “feeding the beast” while out at meetings of the hierarchy rather than on patient-related matters; where clinicians feel disempowered and removed from the responsibilities of management, although they spend all the money; and where the responsibility for training nurses and for generating the quality of care standards and so on is removed from the hospital to a remote body.

I know that there are plenty of scandals in the independent sector care homes, too, which are the result of poor consumer pressure, no competition and ineffectual regulation. But in NHS hospitals it is the profoundly disempowering remote management that encourages NHS managers to fiddle with numerous edicts and instructions while the quality of services may be lamentable. The Government have begun to change things. Over the past decade of Labour government, and before that under Conservative Governments, there has been in this country a policy consensus that hospitals and community health and social care service providers must be freed up and moved from direct control to real, commercial-style autonomous boards with local accountability, where competition, plurality of providers and real choices for patients drive a regulated system judged on clinical and patient satisfaction outcomes, not on proxy process target measures.

The system in health has been mirrored in the policy initiatives in education. We have come a long way in the past decade and I pay tribute to the Government for that. I have been very proud to be part of those reforms, which are now widely recognised as the right approach. Commissioners are focused on understanding local health needs and designing appropriate care pathways. There are real incentives for providers to give efficient, high-quality care through the payment-by-results tariff system and the introduction of real patient choice. Autonomous providers are free to make their own decisions on how best to deliver care that responds to patient and commissioner requirements quickly. The real challenge is whether the Government will keep up the pace of reform. Many of us have watched effective government policies slide into the ground, neglected and half-implemented after a change of Secretary of State. Stepping back at this stage will have grave consequences.



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But what was Gordon Brown’s reaction to the news that, in the public’s view, our hospitals are not getting clean enough fast enough? He issued an edict that all hospitals will have a ward-by-ward “deep clean” to rid them of fatal superbugs. He said that,

across the country,

That is the Prime Minister speaking about hospital ventilation shafts. What will he do when that fails? Will he send David Nicholson out to scrub the bedpans himself? That would be a long job. The noble Lord, Lord Darzi, will say that all US hospitals do the deep clean as a matter of course. Of course, UK hospitals should, too. Indeed, they used to. I participated in the “high sweep” as well as the “deep clean”. The noble Baroness, Lady Emerton, obviously has done so, too, as she is nodding vigorously. I have no quarrel with the need, only the manner of the directive and the fact that once again the centre will determine action, not because hospitals see it as their priority.

The Government must not bottle out and regress to the norm of issuing instructions on cleaning or anything else. If we trouble to look at the history, we will realise that that will not do a jot of good. We must have the courage to be patient and to hold fast to the benefits that we are beginning to see from the reforms in, for example, the NHS foundation trusts, which are delivering higher-quality care than NHS trusts in general. They are delivering strong financial performance. Last year, they delivered a surplus of £130 million and are becoming more efficient. Those people who do not see the point of surpluses should remember that no surplus means no investment, no growth and no improvement. All 19 organisations rated as excellent by the Healthcare Commission for use of resources and quality of services are foundation trusts.

There is growing evidence of the beneficial impact of greater autonomy on foundation trust boards and on managers and clinicians. At Monitor we have now seen more than 100 boards in our very rigorous assessment process. Boards are taking greater ownership of the performance of their trusts. They are and they feel accountable for performance. That is important. Chairmen and boards are starting to behave differently. They see their trusts as autonomous businesses and their role as driving performance, which recruits better chairs. Boards are adopting more professional management approaches with the introduction of service line management, which empowers senior clinicians to take responsibility for their services and puts them in the driving seat.

Let us not forget that there are an estimated 800,000 members of NHS foundation trusts, providing a direct link to patients and local communities. What an opportunity we have to use those members and governors creatively to influence the way our hospitals perform. Yet the Government forget they exist. We need to use those governors and members, who are an excellent vehicle for linking patients and the local community to influence the hospitals.



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