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Thursday, 1 December 2011.
11 am
Prayers-read by the Lord Bishop of Ripon and Leeds.
Housing: Rented Homes
Question
11.06 am
Asked By Lord Kennedy of Southwark
To ask Her Majesty's Government what action they are taking to deal with the shortage of homes for rent.
The Parliamentary Under-Secretary of State, Department for Communities and Local Government (Baroness Hanham): My Lords, the Government are committed to the provision of affordable housing and are investing nearly £4.5 billion to help deliver up to 170,000 new affordable homes, mainly for rent, by April 2015 in England. This is more than the 150,000 originally estimated and means that the Government will be able to deliver more affordable homes in that timescale than had originally been anticipated.
Lord Kennedy of Southwark: My Lords, we have the lamentable failure of the Government on new homes for rent. There is also the impact of 80 per cent of market rent, which means that a family of two adults and two children living in the London Borough of Newham needs an income of £48,000 a year to afford a home without claiming universal credit. Does the noble Baroness understand that, because of the lack of joined-up thinking across government and failed policies, hard-working families are paying the price?
Baroness Hanham: My Lords, that scoops up a whole lot of things, some of which are not entirely to do with me. The universal credit is not part of my department, although I recognise that the housing benefit goes towards the contribution of housing facilities. We are trying to provide, and will provide, affordable housing for as many people as we can. The universal credit and the amount of money paid in housing benefit is something that my noble friend Lord Freud will deal with in due course.
Lord Shipley: My Lords, does the Minister agree with me that the reason for the shortage of homes for rent is the failure of the previous Government, over 13 years, to build council houses? Given the pressure on the private rented sector, and the fact that 40 per cent of homes in that sector do not meet the decent homes standard, what consideration is being given to further regulation of the sector? Will the Minister consider the advice of the British Property Federation, the National Landlords Association and the Association of Residential Letting Agents that there should be a system of compulsory regulation of letting agents to ensure that professional and ethical standards are applied to private sector lettings?
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Baroness Hanham: My Lords, with regard to the last point made by my noble friend, the Minister for Housing, Grant Shapps, has said that he is looking to see whether there is any requirement for letting agents to be registered. He is keeping that under review but there is no plan to do so at the moment. With regard to decent homes, yes, the decent homes money will still be there, and we expect to make a big contribution to that in the next few months and have done so already. Yes, the number of affordable homes was going down, rather than up, under the previous Government, and it is a matter that we are having to deal with.
Baroness Turner of Camden: My Lords, is the Minister aware that one of the problems is the size of the rents that are being charged, particularly in places such as London? For example, in my area of London a two-bedroom flat will cost £500 a week to rent. That is right out of the range of ordinary working people. Is the Minister aware that after the last war there was rent regulation that enabled at least some people to get into affordable homes? Some regulation is needed in this area at present.
Baroness Hanham: My Lords, young people on the waiting list who require affordable homes, or who are being asked to find private accommodation, will, like everybody else, have to see where they can find accommodation that they can afford. That is happening across London in particular. Housing benefit will support what it can, but I am afraid that people either have to pay the additional amount or find somewhere that falls within their capability. I do not think that anybody wants to go back to rent control. It was not helpful, did not leave properties in good condition and was not fair.
Lord Best: My Lords, will the Minister tell us what is happening about the real estate investment trusts, which are the intermediaries that allow insurance companies and the big pension funds to invest in residential property? They have been held up for a long time by the bureaucracy and complexity of the system but we badly need the finances that those big City institutions could put into residential housing. They would probably be rather good landlords. Will she tell us what is happening about those REITs?
Baroness Hanham: My Lords, I recognise entirely what the noble Lord has said. This is a very important aspect of getting money into residential accommodation. I think this matter is still being discussed with the Treasury. I hope that it will be able to say something about that in the not too distant future.
The Lord Bishop of Hereford: My Lords, we have heard questions about the rental prices in London. Will the Minister be kind enough to say something about what the Government are doing to try to ensure that there are more affordable rental homes in villages and the countryside as well?
Baroness Hanham: My Lords, the Government have a number of policies. The right reverend Prelate will know that a community right to build is one of the policies coming forward, which will enable communities to decide whether they can contribute in some way to
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Lord McKenzie of Luton: My Lords, the Minister will be aware of provisions in the Welfare Reform Bill whereby housing benefit will be docked for those tenants deemed to underoccupy their house, even if there is no suitable available accommodation for them to move into. The noble Baroness will also be aware of the announcement on Tuesday about the so-called reinvigoration of the right to buy, with 50 per cent discounts. Will those tenants deemed to underoccupy their house be able to benefit from the right-to-buy provisions at the full 50 per cent discount?
Baroness Hanham: My Lords, I must be perfectly honest that I cannot answer that correctly. I will write to the noble Lord on that aspect. However, as regards the proposal on the right to buy, it is suggested that the discount will go up to 50 per cent, which means that there will be more opportunity for people to take advantage of the right to buy. The other side of that is that, unlike in the past where a substantial proportion of a deposit had to come back to central government, it will be retained locally so that it can be used to provide further affordable housing.
Lord Cormack: My Lords, will my noble friend recognise that although the right-to-buy policy was rightly and widely welcomed, and many of us welcome what the Chancellor said in outline, nevertheless it took a lot of houses out of the affordable bracket? It was a particular mistake to allow those occupying old persons' bungalows to buy their houses because it meant that their children bought them and then sold them on at a great profit, thereby depleting the stock of that sort of housing. Can we please not repeat that mistake?
Baroness Hanham: As I said in my previous answer, any money that comes from right to buy will be invested in new affordable housing. As for residential homes, they are slightly different to the mainstream right to buy, but I note what my noble friend says.
Pakistan
Question
11.15 am
To ask Her Majesty's Government what is their assessment of the contribution made by Pakistan as the front-line state in the "war on terror".
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The Minister of State, Foreign and Commonwealth Office (Lord Howell of Guildford): My Lords, Pakistan remains an important partner in the fight against terrorism. As my right honourable friend the Prime Minister stated following his meeting with President Zardari on 4 July last,
The al-Qaeda core has been severely weakened over the last six months. It is important that the UK and Pakistan, together with other key international partners such as the United States, continue to work together to disrupt terrorist groups which threaten all our interests.
Lord Ahmed: I thank the Minister for his reply. Will he join me in sending condolences to the families of 26 Pakistani soldiers who were killed by a NATO air strike a few days ago? Is he aware that Pakistan has lost over 30,000 civilians and over 5,000 soldiers-more than any other country in the world-as well as $75 billion to $80 billion, and that Pakistan has hosted over 6 million refugees from Afghanistan? Separating the sacrifice made by the people of Pakistan from Ali Baba and his 40 companions, will the Minister assure the House that the British taxpayers' money allocated to DfID for education and training teachers will not end up in this individual's private accounts in Switzerland?
Lord Howell of Guildford: Yes, my Lords, as regards condolences, I certainly join the noble Lord. In fact, my right honourable friend the Foreign Secretary spoke to the Foreign Secretary of Pakistan only the other day to offer his deepest condolences. A full investigation of that really tragic and dreadful incident is, of course, under way. I hope Pakistan will participate fully in that investigation. The United States has expressed its regret at the loss of life.
As regards the suffering faced by Pakistan, I think we all acknowledge the colossal strain on Pakistan, its society and all its citizens, with the conditions they face not only on the terrorist side, but also through the visitations of floods and other challenges, all of which add great difficulty to Pakistan's administration. As for our aid, I can assure the noble Lord that all our aid is independently evaluated and scrutinised under our UK Aid Transparency Guarantee, and that certainly applies to all aid to Pakistan as well.
Lord Stirrup: My Lords, will the Minister agree that the most telling contribution Pakistan could make to global security would be to improve levels of effective governance, economic growth and employment within its own borders, and that the international community should not allow its frustration over other issues, however understandable, to divert it from this strategic focus in its engagement with Pakistan?
Lord Howell of Guildford: Yes, that is an extremely wise observation, and I think that Her Majesty's Government would totally agree with it.
Lord Avebury: My Lords, I add my condolences to the relatives of those who lost their lives in the tragic event last week. I ask the Minister whether consideration will be given to postponing the Bonn meeting to allow
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Lord Howell of Guildford: No, I do not think it would be right to seek postponement of the Bonn meeting which is coming up, and we urge Pakistan to join. I know that in its dismay at this whole event it has thought about not joining, and in a sense that is understandable. But one looks for second thoughts and hopes that Pakistan will join the meeting. It is not a meeting organised by or about NATO, it is about the whole future of Afghanistan. Pakistani involvement would be valuable and we strongly encourage it. We stick to the timetable that has been planned.
Lord West of Spithead: My Lords, while I was Minister for Security for three years, the country of gravest concern to me globally was Pakistan. Notwithstanding the huge efforts, huge sacrifices and so forth that have been made in Pakistan, does the Minister not agree that one of the greatest risks to that country is violent, extremist terrorism within and around its borders and not threats from India? The fact that India is being looked at by some people within the ISI and the army as the greatest threat has diverted its efforts.
Lord Howell of Guildford: The noble Lord makes an extremely good point. Pakistan has many problems but very high on the list are the terrorist threat and its borders with Afghanistan, as we all know. As to relations with India, we notice that India and Pakistan have recently been talking. We greatly welcome and encourage their dialogue, which we hope will lead to a less tense development on that side and therefore less distraction from the main aims that the noble Lord has rightly identified.
Lord Ahmad of Wimbledon: My Lords, accepting that Pakistan has been in the front line in the war on terror for the past 10 years, I seek our Government's assurance that strategically, militarily and tactically on the ground Pakistan's role will not be diminished and that it will continue to play an integrated role in the war against terror-not watching on the sidelines but being involved and engaged fully to prevent the kind of incidents that we saw recently with attacks on Pakistani forces within Pakistani sovereign territory. I join in extending condolences to the families who suffered loss as a result of that act.
Lord Howell of Guildford: I am sure that my noble friend's condolences will be appreciated. These horrific things do happen, and we await an investigation of what on earth went wrong for this to have occurred. Full integration in counterterrorism is very much our purpose. As the House knows, we have counterterrorist
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UK Border Agency: Prisoners
Question
11.22 am
To ask Her Majesty's Government what is their response to the recommendations by the independent Chief Inspector of the UK Border Agency on how the agency manages foreign national prisoners.
The Minister of State, Home Office (Lord Henley): My Lords, this is an important report and the United Kingdom Border Agency has taken its recommendations seriously. Of the eight recommendations, four were accepted in full, three in part and only one was rejected. We have taken steps to implement and reinforce policy and procedures relating to the management of foreign national offenders. I have placed a copy of the full response in the Library.
Lord Avebury: My Lords, I thank my noble friend for that response, but does he not agree that the UKBA's lukewarm response to the Chief Inspector's recommendation that it should reduce the number of decisions that are overturned on appeal was disappointing? As the UKBA must have a good idea of the likely adverse decisions of the court in most of the one-third of appeals that it loses, is it not both perverse and costly to the public purse to continue acting on the presumption that, where the deportation threshold is met, only in exceptional cases will deportation breach Article 8? Secondly, what is the Government's strategy for reducing the number of foreign nationals who remain in prison after their sentences have expired, mainly because of non-co-operation by the prisoner or his embassy with the process of obtaining an emergency travel document?
Lord Henley: My Lords, I do not accept that our response to that particular recommendation was lukewarm. We accepted it in part and we accept that there is a need to improve the quality of our decision-making. We also accept that it is necessary to increase the number of those whom we manage to deport, as and when their sentences end. The number of those who have not been deported has come down steadily over the past few years.
Lord Hunt of Kings Heath: My Lords, is not the reason for the potentially muted response of the UKBA and the Government to this report because the core conclusion is that the quality of decision-making needs to be improved? The UKBA is faced with a 20 per cent cut in its budget and major new responsibilities. No wonder the Border Agency does not have that much confidence in improving the quality of the work that it is doing.
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Lord Henley: My Lords, the UK Border Agency has confidence that it can improve these things and that it can do this within the perfectly manageable reductions that it is facing as a result of, as we have said on a number of occasions, the actions of the party opposite when in government. The agency will be able to improve its decision-making and it accepts that it needs to improve its quality.
Lord Ramsbotham: My Lords, the executive summary to this report mentions that,
"By January 2011, over 1,600 foreign national prisoners were detained under immigration powers at the end of their custodial sentence, pending deportation".
I remember that, as Chief Inspector of Prisons in 1999, I recommended that the default position should be that prisoners sentenced to deportation should have that deportation processed while they were in prison, so that at the end of the sentence they went straight to the airport and out. Why were more than 1,600 still detained after the end of their custodial sentence?
Lord Henley: My Lords, there are frequently problems dealing with the country that the individual prisoner is going to and arranging travel documents. I remember the recommendations made by the noble Lord and that is something that we shall have to address in due course. Obviously, the best way of dealing with that would be to start the process somewhat earlier.
Riots Communities and Victims Panel
Question
11.26 am
Asked By Lord McKenzie of Luton
To ask Her Majesty's Government what is their response to the recommendations for immediate action contained in the interim report of the Riots Communities and Victims Panel published on 28 November.
The Minister of State, Home Office (Lord Henley): My Lords, we welcome the interim report from the independent Riots Communities and Victims Panel into the serious events of last summer and will study its findings carefully. There are a very large number of recommendations, which we shall consider in detail and with care.
Lord McKenzie of Luton: My Lords, I thank the Minister for his reply and for his welcome of the report. Does he agree that we are indebted to the panel that produced the report and for its work so far, including that of my noble friend Lady Sherlock? The report offers many challenges to government, local authorities, community organisations and faith communities, and cites positive examples of young people who are responsible, ambitious, determined and conscientious, despite having deprived backgrounds. It also says that for many there is a common theme of people needing hopes and dreams, and that a sense of
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Lord Henley: My Lords, as the noble Lord will be aware, the report came out only on Monday this week, so it is a bit early to make a very detailed response to all the recommendations. I have had a brief chance to look at the report but I have been engaged in other business in this House for most of the week. The report addresses itself not just to the Home Office but to other government departments and, as the noble Lord quite rightly said, to a whole host of other groups all of whom will need to consider what is in it.
Further, we await a report from HM Chief Inspector of Constabulary, the Met and the police in Manchester and Merseyside. The IPCC is also conducting a report, so a great deal will have to be looked at in due course. It would be wrong to announce too early how exactly we will respond to the very many recommendations in this report.
Lord Cotter: My Lords, on 11 August, I asked the Government,
to assist businesses in riot areas-
- "are taken very speedily, with minimum red tape and bureaucracy".-[Official Report, 11/8/11; col. 1526.]
In my Oral Question on 13 September, I asked the Business Minister to,
On both occasions I received reassuring replies. I am shocked to learn from the report that many people have not yet had any compensation at all. Indeed, seven months after the riots in March the expectation from the report is that nearly nine out of 10 large claims and as many as half of small claims for business will not be met. It is likely that this situation will be answered-
Lord Cotter: I want to ask the Minister to ensure that we get a clear response now on behalf of business because I feel that it is inexcusable and that there is a sense of betrayal. Will the Minister give us a response quickly?
Lord Henley: My Lords, a number of the recommendations relate to the Riot (Damages) Act 1886, the Act that governs compensation for businesses that were affected by the events last summer. I will answer a Question on this subject in two weeks' time. The immediate recommendations from the interim report were that there should be an extension of the deadline for the submission of claims. I can confirm that we will look at that, just as we will look at the workings of the whole of the Riot (Damages) Act in due course.
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Baroness Sherlock: My Lords, I thank the Minister for that comment in particular. As a member of the Riots Communities and Victims Panel, I had the privilege of meeting a great number of people and was very moved and shocked by stories of loss and trauma, so I welcome the fact that the Government will look at the Act.
Two things were raised most often with us. First, we did not meet a single person who had received a payout under the Riot (Damages) Act. Has anyone had such a payment and, if not, will the Government move to overhaul the Act in some detail? Secondly, there was a sense that people in areas hit by riots felt that they had been abandoned by the police. I met some hugely brave police and PCSOs who had gone out there and risked their lives. Will the Minister comment on what the Government will do in response to make sure that police tactics are appropriate for the kind of disorder we now see? That means smart policing, not just tough policing.
Lord Henley: My Lords, I congratulate the noble Baroness on her contribution to this report as one of the four members of the panel. We are very grateful to her for all her work. We will review the Riot (Damages) Act. It is a fairly ancient bit of legislation and obviously needs looking at. We will also review police tactics and how they worked and we will look at the reports from the Met and other police authorities. We should also look at the areas where we had no riots because there are possibly lessons to be learnt from why there were riots in some places and not in others. There will be a great deal to consider and no doubt the noble Baroness and her panel will produce yet more for us as this was only an interim report. I look forward to that, and the Government will respond in due course.
The Lord Bishop of Ripon and Leeds: My Lords, one of the most heart-warming flipsides of the tragedy of the riots that comes out from the report was the way in which it brought out the best in so many people, including many young people. What can the Government do to recognise and honour those who supported communities during the riots, those who cleaned up afterwards and, indeed, those who, in many cases, prevented riots developing in the first place?
Lord Henley: My Lords, the right reverend Prelate is quite right to draw attention to all those who did such sterling work during and after the riots. We all owe an immense debt of gratitude to them. I think we should also learn what we can about how some communities came together and either prevented riots or cleaned up after them. Again, I believe that there are lessons to be learnt, and the Government will take note of that in due course.
Baroness Kingsmill: My Lords, in the light of the Minister's remarks on the riots and in the light of his obvious condemnation of the violence that was incurred by them, will he also add his voice to those condemning the remarks of Mr Jeremy Clarkson last night that strikers should be put up against a wall and shot in front of their families?
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Lord Henley: My Lords, I am not, fortunately, responsible for the remarks of Mr Jeremy Clarkson and do not have to answer for him, but I think the noble Baroness can imagine what I think about his remarks.
Lord Elystan-Morgan: My Lords, will the Minister assure the House that in looking at the operation of the 1886 Act, consideration will be given not only to extending the time limit for a claim, which I think is a few weeks, but to the whole ethos of the Act: that is, the question of claiming against police authorities and the fact that the Act goes back a century and a quarter to a period when policing was much more formative in its development than it is nowadays?
Lord Henley: The noble Lord is right to draw attention, as I did earlier, to the age of the Act. It is possibly coming up to its sell-by or use-by date, which is one of the reasons why we want to review it. The recommendation in the report was that the submission of claims should be extended to 90 days. The Government had already extended it from 14 to 28 days. Extending it to 90 days is a very interesting suggestion and will be looked at as part of a wider review of the whole Act.
Baroness Symons of Vernham Dean: My Lords, will the Minister answer the specific question raised by my noble friend Lady Sherlock? Have any compensation payments been made so far?
Lord Henley: My Lords, I apologise for not answering that part of the question. My understanding is that some payments have been made but I confess that the number is very few. We would like to see more paid in due course, although we want to make sure that the right claims are paid. There have, in some areas, been rather a large number of claims and one suspects that not all of them are quite as valid as others.
Caravan Sites Bill [HL]
First Reading
11.36 am
A Bill to make provision to secure the establishment of caravan sites by local authorities in England for the use of Gypsies and Travellers
The Bill was introduced by Lord Avebury, read a first time and ordered to be printed.
Business of the House
Timing of Debates
11.36 am
That the debates on the Motions in the names of Baroness Emerton and the Earl of Sandwich set down for today shall each be limited to two and a half hours.
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Procedure of the House Committee
Membership Motion
11.37 am
Moved By The Chairman of Committees
To move that Lord Campbell-Savours be appointed a member of the Select Committee in place of Lord Goldsmith.
Nursing
Debate
11.37 am
Baroness Emerton: My Lords, I welcome the opportunity to introduce this debate to take note of first-line nursing care. The timing of this debate is opportune for several reasons, not least that the Health and Social Care Bill is currently in Committee, giving an opportunity for amendments to the Bill that are considered helpful to the implementation of the proposed Health and Social Care Act.
The professions of nursing, midwifery and health visiting-the largest single workforce in the NHS-plays an important part in delivering high-quality care to patients. The NHS is currently facing the Nicholson challenge of saving £20 billion within the next three years, not avoiding cuts in service provision. The scene is therefore one of challenge: meeting the forthcoming organisational changes while maintaining and developing new approaches to the delivery of high-quality care. That inevitably causes a mixture of anxiety and excitement: anxiety for job prospects, but excitement at the opportunities opening to the profession by moving to an all-graduate profession and by meeting the patient's needs holistically, with integrated patient pathways through primary, secondary and tertiary care, then back to primary care and care in the community, where the patient can be cared for in their home and supported by the NHS and social care with as much independence as possible for the individual and closeness to their family.
Where do the professions of nursing, midwifery and health visiting want to see themselves in the newly reorganised health and social care services so that they can deliver the high-quality care required and innovate in developing the new procedures that will result from research evidence, which will in turn result in best practice and be cost-effective? I declare my background in nursing. I am retired and not on the effective register of the NMC. I am a fellow of the Royal College of Nursing and president of the Florence Nightingale Foundation.
I should like to address concerns that have been raised in recent months about the move to degree-level registration for nurses. As my fellow commissioners
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It is vital that the focus is not just on what education and training nurses and midwives should receive in their pre-registration courses. Equally important are the development of post-qualification training pathways for nursing, which are sadly not funded in the same way as our medical counterparts. The funding exists in the current education and training budget to fund junior doctors' salaries and postgraduate placements to training. We wish to see this extended to nurses and midwives so that they can continue to improve and develop throughout their careers and in particular, in the early years after registration. I would be very grateful if the Minister could confirm if the forthcoming publication of education and training will address the lack of central funding for post-qualification pathways for nursing, midwifery and health visiting.
The Royal College of Nursing, the Royal College of Midwives and the Queen's Nursing Institute have all recently published reports reflecting the staffing levels currently being experienced and the urgent need to address the whole issue of workforce planning, taking into account the recommendations in the current Bill. The increase in community care is going to require an increase in community nurses-that is, district nurses-to meet the nursing care needs of those transferred from secondary care following admission to hospital, those suffering from long-term conditions, the treatment of the elderly, frail and vulnerable who require care and support to live independently, and not forgetting those who choose, in increasing numbers, to have end-of-life care at home.
These demands from the community will require highly qualified nurses facing a very different setting, with support and mentoring to adjust if moving from secondary care into the community setting. This means that the workforce planning for the forthcoming changes in the community will need to include the training requirements, not only the professional qualifications, for an induction into health and social care spanning NHS and local government management systems, and third sector involvement in health and social care. The
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Working in the community places different demands on the community nurses than those working in secondary care and there is much to be learnt in regard to working with social services and voluntary organisations, and not least the families, carers and neighbours of those for whom they care.
Research evidence from the United States, Canada, Australia and here in the UK clearly demonstrates that a higher ratio of registered nurses to support workers results in lower mortality and morbidity. It shows that 26 per cent of patients are more likely to die where nurses have the heaviest work load and 29 per cent are more likely to die after a complicated hospital stay. Seventy-two per cent of nurses with the heaviest workload showed negative job outcomes, burnout and job dissatisfaction and saw their hospitals' care standards deteriorating.
Aiken's study in the US demonstrated that every one patient added to the average, hospital-wide nurse workload increased the risk of death following common surgical procedures by 7 per cent. The UK evidence was recorded in 2007 by Anne Marie Rafferty. I ask that this research evidence be studied by the Government and that a cost-benefit analysis be worked on to see whether workforce numbers could be refined to take account of these findings in order not only to reduce morbidity and mortality but also to shorten length of stays, improve clinical outcomes and reduce infection, readmission rates and possibly the number of hospital beds. It should be recognised that community staff should be trained and in post in order to receive the increased workload.
Any reorganisation of services requires an in-depth analysis of the effects that the changes are going to cause and the means of solving the identified issues. As the nursing and midwifery professions and health visitors form the largest single part of the NHS workforce and play a vital part in delivering high-quality, safe care with compassion, respect and dignity, the implementation programme requires leadership from the profession nationally and at CCG level, as well as at the point of delivery of care, from ward sisters in secondary care and from nurse and midwife leaders in the community.
Nursing could best be described as the art and science of delivering high-quality, evidence-based care. The history of nursing demonstrates that nurse leaders effected changes in the development of the profession by exercising their powers of leadership through influence and persuasion, a leadership exemplar being Florence Nightingale, who influenced practice, education, research and public health and through evidence presented to politicians. Mrs Bedford Fenwick introduced the nursing register and regulation in 1919 after attempting to have six Private Member's Bills passed in Parliament and 30 years' struggle. Other examples are the Salmon
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The involvement of politicians has been central to the implementation of these changes. One could describe politics as the science of government. Nurses, midwives and health visitors need to exercise their leadership skills by influencing and persuading government with evidence that will lead to changes in the profession, leading to higher-quality, evidence-based, safe and cost-effective care to the satisfaction of patients, relatives and the public. However, while it is recognised that implementation of research-based change takes time, can we wait 30 years to see a reduction in morbidity and mortality rates among patients?
Given the current economic situation and the recent negative reports on care delivery, there is a very important task to be achieved in regaining the public's and patients' confidence in the profession. There is no doubt that we have excellent nurses and midwives throughout the country, but sometimes there are failures, usually due to a systems failure in the organisation. It is therefore important that the status of the professions is raised in the eyes of the public and patients. This can be done only by addressing the professional issues as well as the organisational team, starting with the board, providing them with clear sets of values and objectives to which the whole organisation is committed, with clear lines of accountability and authority.
My passion is to see nursing care of world-class standard, but as well as attacking the issues within the profession there is the overriding need to address the culture within the NHS so that all professions and support staff are committed to ensuring that the part they play contributes to the change in culture-that is, compassionate care with dignity and respect throughout the workforce; and staff valued, which in turn is projected to all patients, relatives and the public, restoring the view that the NHS provides excellent compassionate care with dignity and respect to all. This would override the rather negative and critical view that pervades at the present time in some places. I beg to move.
11.51 am
Viscount Bridgeman: My Lords, I thank the noble Baroness, Lady Emerton, for her expert and sensitive treatment of this subject. I am afraid what follows now will be a slightly inadequate summary of what she began by saying and reverted to later in her speech-that is, the fundamental challenge to the training of nurses in the United Kingdom. As she reminded us, the trend over the past 10 years towards the requirement that nurses should be educated to degree standard is a desirable objective in itself. It makes nurses better equipped to address the ever increasing sophistication, both in treatment techniques and in equipment, and crucially it gives student nurses who are so motivated the chance to aspire to management positions within healthcare.
The downside of this, to which the noble Baroness has referred, is that during this period of nurse training a decreasing amount of time is spent on the ward with
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I have some recent experience of the healthcare sector as a former chairman of an independent hospital in London, the Hospital of St John and St Elizabeth. On the whole, the independent hospitals have been able to retain the traditional system of the matron having total responsibility for the nursing staff, with the ward sister or manager looking after patients on the ward and, crucially, having responsibility for services such as cleaning. It would be both arrogant and unrealistic, coming from the independent angle, to say "If we can do it so can you". There are so many differences between the environments of the National Health Service and the independent sector that it makes such a glib suggestion inappropriate, not least the organisational demands which a body the size of the National Health Service faces. Furthermore, on a personal note, I wish to place on record the great help and support the hospital with which I was associated receives from the NHS in many, many ways. There should be no misunderstanding about this-I am not referring to financial help. However, it is important that the two sectors have regard for each other, possibly to their mutual benefit.
Let me recount one experience I had which I think may be relevant to this debate. While the independent sector struggles to attract good nursing staff as much as the NHS, most are fortunate in having a satisfactory body of trained nursing staff. However, many of these hospitals, including my own, also operate a programme of giving work experience to trainee nurses in the NHS. Ours formerly involved an arrangement with one newish university in the London area. On more than one occasion, Matron was somewhat startled to come across the attitude "I am not interested in the nursing, I am only here to get something on my CV". Subsequently-and understandably- the change was made to sourcing from one of the London teaching hospitals where we encountered a totally different type of student nurse-keen and committed, potentially a credit to the nursing profession.
The wastage of resources in the nursing training programmes of some institutions is self-evident and I would welcome an assurance from the Minister that his colleagues in the DoH are monitoring this, and particularly the suitability of candidates for these training schemes. My message to your Lordships-and, indeed, the Minister-is that I see no easy, quick-fix solution to the present less-than-perfect juxtaposition between academia and ward experience.
In conclusion, perhaps I may return briefly to the subject of ward cleaning. Many are the complaints one hears that the ward was dirty and that the ward manager was unable to do anything about it because
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11.55 am
Baroness Warwick of Undercliffe: My Lords, I thank the noble Baroness, Lady Emerton, for providing this opportunity to highlight this crucial aspect of our national healthcare provision. Her distinguished leadership and experience in the nursing field give enormous weight to her observations today. She is a doughty advocate for the nursing profession.
There cannot be anyone in this House who has not at one time or another had cause to be grateful for excellent nursing care. However, we may also know of, or have experienced, less than compassionate care, or even neglect or indifference, from overstretched nursing staff. Like others, I am horrified by some of the stories that have appeared in the media, and we cannot ignore the shocking failings uncovered, for example, at the Mid-Staffordshire NHS Trust. Sadly, it would be wrong to suggest that the unfortunate cases that hit the headlines are entirely anomalous or isolated incidents. Indeed, it seems that not a week goes by without another story revealing a lack of care and compassion and arguing that standards are falling.
Some of those who claim this most vociferously blame the lack of compassion on the move to make nursing a degree-level profession. Like the noble Viscount, Lord Bridgeman, I want to focus my remarks on the area of nurse education. I want to challenge most strongly the line put forward in the media-and, indeed, on occasion in this House-that some of the recent instances of lack of care are because nurses are now all graduates and consider it beneath them to clean bedpans or clean after the vulnerable and sick in their care. The "too posh to wash" arguments favoured by newspaper columnists do not stand up.
Studies in England, Scotland and Northern Ireland have shown that graduate nurses spend longer hours working in clinical areas than their non-graduate counterparts. American studies have found that graduate nurses stay in the profession, on average, four years longer than non-graduates and, in addition, they tend to stay at the bedside more often, working with older people and those who are terminally ill. US research-it is a shame to quote only US research but there is very little research in this country on this area-has also noted that graduate nurses acted more independently and took more responsibility for their professional judgment.
The point I wish to make is that there is not, and should not be, a distinction between professional academic head on the one hand, and caring heart on the other. As the excellent report, Front Line Care, asserted last year:
"Truly compassionate care is skilled, competent, value-based care that respects individual dignity. Its delivery requires the highest levels of skill and professionalism".
The core values of care and compassion do not change even as nursing becomes more demanding and complex. The challenges that nurses face today require
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"To ensure high quality, compassionate care, the move to degree-level registration for all newly qualified nurses must be implemented in full ... There must be greater investment in continuing professional development."
I strongly support this position and I hope that the Minister, in replying, will confirm that the Government do too. Nurses practise in increasingly complex clinical and social environments.
The decision in 2009 that all new nurses must hold a degree-level qualification to enter the profession from 2013, was made with the aim of increasing skills, and training a medical workforce capable of operating in a more analytical and independent manner. I believe that making nursing a degree-level profession is the way to ensure high-quality front-line patient care. Currently, one in four nurses has a degree as their highest qualification, and I believe this must grow. As the noble Baroness, Lady Emerton, reminded us, this would merely enable us to catch up with Wales and Scotland and several countries in Europe and elsewhere-indeed, as well as with other professions.
I believe that it is a mistake to view being academically qualified and being a caring professional as somehow incongruous. This is not assumed in medicine or clinical psychology, so why should it be in nursing? Compassion is vital, but it is not enough; nurses must also be well educated to deliver safe, effective care. All nurses need to put quality care at the centre of what they do, but they also need extensive knowledge, analytical skills and experience to work in a variety of settings.
I know that universities strive to ensure that students entering the profession have the right blend of personal, caring attitudes along with the necessary knowledge and practical skills to deliver high-quality, evidenced-based nursing care for patients. This is why, as the noble Baroness reminded us, half of university-based education programmes at both degree and sub-degree level continue to be delivered on the ground, in health practice. Of course, there can always be improvements, and I know that universities and hospitals themselves are striving to make those improvements. But education and training must not stop at the point of registration. It must continue to consider post-qualification pathways for recently registered nurses, and recognise the importance of both multi-professional training and continued professional development.
Many noble Lords have raised the importance of education and training in a reformed NHS as the Health and Social Care Bill goes through Committee, and we have been reassured that the Government will give this area due weight and consideration on Report. Will the Minister reassure us today that, in its plans in the Bill for ensuring the continuation of appropriate education and training across the health professions, and developing a well educated and compassionate workforce, the new system will ensure continued professional development?
My final point is to echo some of the points made by the noble Baroness, Lady Emerton, that front-line nursing care is being severely threatened by the £20 billion efficiency savings target set by the NHS. The Royal College of Nursing's Frontline First campaign has been monitoring cuts in NHS services and posts since
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The need to provide skilled care for people with many different conditions will continue to grow; we must have sufficient nurses, and our nurses must be properly equipped and supported to provide that skilled care.
12.05 pm
Baroness Jolly: My Lords, I thank the noble Baroness, Lady Emerton, for inspiring this debate. Hers is one of the most respected voices in your Lordships' House, and when she speaks on this subject we all listen and learn. I am also delighted to see here in the Public Gallery nurses who have come to listen to the debate.
What is the front line? All but a few of the 600,000-odd nurses are working right there, delivering world-class care to their patients. Some will be in key management positions in our trusts and a few are top civil servants advising the department and strategic health authorities. They are members of clinical networks, and I hope that in the new world they will be advising the NHS boards and should be on clinical senates.
If you were to talk to a focus group of the general public and ask them to close their eyes and think of a nurse, what would they say? In all probability they would think of a woman. Depending on their age, they might put that nurse in a frilly starched cap, and almost certainly in a hospital at the sharp end of acute medicine-including theatre, A&E, intensive care and neonatal nursing-although those with recent experience of the NHS might have a more modern, nuanced view. Of course, that picture is not accurate. Many nurses are men, and in the days of infection control frilly caps have gone. This focus group might be surprised that it is a graduate profession and that there are many specialist nurses with the equivalent of masters' degrees in their specialism. This situation is completely unrecognisable from that of 20 years ago. Let us be completely clear-here I totally agree with the noble Baroness, Lady Warwick-that, despite much red-top protestations to the contrary, all but a very few nurses do their jobs with utmost professionalism, as they fit into a multidisciplinary team based around patient care.
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I shall focus my remarks today on the nurses whose front line is the local community and who work in community settings, in the home and in community hospitals. They are largely unsung but play a vital role in patient care. They give the patients what they want-personal care at home or close to home. Their role is vital in keeping patients out of the acute setting wherever possible and in taking tasks from doctors, who are thus freed up for diagnostic work. We should be in no doubt that this is not only good news for the patient but, incidentally, delivers considerable savings to the NHS.
What roles might nurses take in community care? They are involved with cancer, continence, COPD, diabetes, district and community nursing, end-of-life care, learning disability, mental health, midwifery, minor injury nursing, multiple sclerosis, older people, practice nursing, prescribing, renal, school nursing, smoking cessation, stroke and substance misuse. My list is not exhaustive, and I apologise unreservedly for any areas that I have omitted. These nurses are quietly innovative. The way that they work improves the care of their patients. They are collaborative and forge links with GPs, acute care, charitable sector providers and local authorities. They were designing informal packages of care and pathways before those terms were in common parlance. They act, while others plan and strategise.
In the history of community specialist nurses, midwives get the earliest mention in literature, in Exodus, delivering babies as the tribes of Israel fled from Egypt-if anyone can go back more than 6,000 years, I am happy to hear of it. This is a far cry from the world that my noble friend Lady Cumberlege spoke about on Monday in Committee on the Health and Social Care Bill. I should like to highlight two areas of outstanding care. Your Lordships will know that I worked for Macmillan Cancer Support, and I should like to explain its work in the community, and the role of minor injury nurses.
Last Sunday, I attended a service in Exeter cathedral to celebrate 100 years of Macmillan Cancer Support, which was established by Douglas Macmillan in response to his father's death from cancer. There are now thousands of Macmillan-trained nurses in the community, offering services such as chemotherapy at home, wherever possible, and helping the whole family deal with end of life, where necessary. At present, only a quarter of patients are able to die in their own beds, and 24/7 community nursing is critical to helping cancer patients die at home. These front-line nurses prevent crisis situations from occurring, so that patients are not transferred into hospital and hence reduce costs to the NHS in the longer term. However, half of PCTs are not providing this vital service. The palliative care funding review recognised that a relatively small investment in 24/7 community services would enable commissioners to deliver improved outcomes for patients and ensure that palliative and end-of-life care services are delivered in the most cost-effective way. The new draft end-of-life care quality standard also supports the need for 24/7 community nursing, and Macmillan would like to see the standard implemented effectively and as quickly as possible. Macmillan is also supporting those living beyond cancer. Macmillan nurses help families link
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On minor injury nurses, every week millions of people go to A&E or their own doctor for conditions that are minor-neither an accident nor an emergency. They go because A&E is easily accessible, but they waste the time of trauma teams. Two highly skilled specialist nurses in a community hospital or within an A&E department can run a minor injuries unit. They have access to advice from the A&E department as and when required. These units are able to treat a range of conditions: cuts, bruises, burns, simple fractures -even broken bones, as long as the skin has not been broken and the bone does not stick through-as well as sprains, strains and head injuries. Saturday afternoons see them full of sportsmen and women. In one year in Cornwall, 900,000 patients attended a Cornish minor injury unit. This prevented nearly 1 million attendances at A&E. By anyone's reckoning, that is an impressive record. If we visit their websites, praise for their service is fulsome. Holiday-makers visiting Cornwall, in Newquay, St Ives or Bude, leave messages on the websites to say how impressed they are by the services and asking why they are not offered locally.
I would like to move on to two general points about specialist nursing. Changes to the workforce need to be patient-centred and must not be undertaken simply as a cost-cutting exercise. There is anecdotal evidence that, in some cases, services are downgrading roles simply to save money without analysing the needs of patients. Changes to the workforce need to be thought out and patient-centred, mapping needs against skills. Macmillan is looking at how cancer patients can be given one-to-one support by a team of different professionals so that they receive support from the right person at the right time. In particular, Macmillan is looking at how support workers can be used to release capacity for specialists so that they can concentrate on tasks that make best use of and develop their skills, thereby improving the productivity and efficiency of teams.
I would like to echo remarks made by the noble Baroness, Lady Emerton, the noble Viscount, Lord Bridgeman, and the noble Baroness, Lady Warwick. I suspect that the speakers who follow might agree, although I dare not anticipate your Lordships' speeches. Education and training must be protected if we are to ensure a high-quality future nursing workforce. I am extremely concerned that under the current financial constraints, education and training budgets are being cut. In addition, there is not the capacity or funding to free up professionals to attend such training. Neglecting the continued education of professionals hampers their ability to advance their knowledge to meet the new and emerging needs of patients and threatens the future supply of specialist nurses. I would welcome assurance from the Minister on this subject.
This has been a very interesting and important debate. Its timing within the Committee stage of the Health and Social Care Bill is really useful. We must
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12.15 pm
Baroness Masham of Ilton: My Lords, I thank my noble friend Lady Emerton for securing this debate on front-line nursing care. Whatever health Bill comes before us as new legislation, nothing will improve unless caring, compassion and dedication are put back into nursing. There is a lack of leadership and the lack of anyone taking responsibility on some wards, which are understaffed and badly managed. If there was a referendum on whether to bring back the old-type matron, who was in charge of nursing within the whole hospital and sisters who were hands-on and in charge of their wards-and the cleaning and helping of patients with their problems and discharge-wards would be better run.
Many of the tiers of nursing administration should be dropped; I am sure that the public would agree overwhelmingly. It is leadership and responsibility that is needed with front-line nurses. There is no doubt that hospitals are challenging places to run and that good administrators are vital but, again, there should not be overload and they should not be in conflict with clinical staff. The safety and well-being of patients should be the priority, and working in harmony is surely better. A consultant told me the other day that she had gone to the ward to see a patient and asked a nurse for the notes. The nurse retorted that the patient's nurse was not there that day, so I ask: was no one looking after her? This attitude is so unhelpful and the culture needs changing.
The other day, I was telephoned by a very popular GP who retired last year but still trains doctors. He told me that one of his trainees had a very rare condition that needed a life-saving operation, but the funding was not forthcoming. It is becoming a desperate situation. Knowing that his wife nursed part time in the local hospital, I asked how she was. The answer came back that she had become so concerned about patient care and nurses going off sick that she had not been sleeping at night, and had worried so much that she has now left. This nurse was Guy's trained and could not go along with the lack of staff and poor standards. It was one of the good days for patients when she was on duty. A culture of indifference to patients seems to have crept in with many nurses.
Having said that, I know that there are some excellent nurses and, for anyone who appreciates good nursing, they shine like bright stars. This being World Aids Day, there will be a debate on HIV and AIDS later today, and I have been so pleased to meet some very dedicated and kind nurses working on wards with AIDS patients. Perhaps this is because they have chosen this specialty and it is more than just a job. This is also the centenary year of Macmillan nursing-many congratulations to that splendid organisation, which has about 5,000 specialist nurses throughout the country, helping and advising people with cancer, while volunteers raise money by all sorts of ways. For many long-term conditions, specialist nurses are vital for illnesses such as diabetes, Parkinson's disease, stroke, epilepsy and so many other conditions. They teach patients and carers,
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Most importantly, however, there are cuts to nurses, including those qualified in specialised neonatal care, and this cannot go on. There is a serious situation at the moment because the £20 billion Nicholson efficiency savings are causing cuts in important front-line nursing staff. For example, when nurses retire they are not being replaced. It has been brought to my attention that there is considerable anecdotal evidence that demonstrates how the district nursing service has been stretched to the point that it is providing a bare minimum service in many areas. District nurses are vital if patients who need nursing care in the community are to manage. The importance of district nurses should be recognised. Skills needed for nursing in the home are different from other forms of primary care nursing. I hope that the Minister will look into what is happening across the country.
With all the recent reports about the lack of care for the frail and elderly, and the horrific evidence shown in the "Panorama" programme of cruelty to people with learning difficulties in a care home, it seems that care assistants should be registered and regulated. I am among many people who feel that it is of great concern that nurses can be struck off their register and take unregistered jobs as care assistants. Patients are being put at risk, as it is unrealistic to think that the few nurses on a busy ward can supervise both care assistants and student nurses when there are vital jobs that only the nurse can do behind closed curtains. There should be training for all care assistants. They are often dressed up in uniforms which are indistinguishable from trained nurses, which is not open and honest to patients.
On a positive note, I would like to say what an excellent job nurses do in front-line nursing in Afghanistan. There seems to be real team co-operation while working under stressful conditions.
Prevention of infection has become more important than ever, given the increasing resistance to antibiotics. I would like your Lordships to realise the importance of infection control nurses working on the front line. There is much concern about moving the Health Protection Agency, which is vital in the fight against infections. Any dilution of its independence and ability to research will have an effect on front-line nurses in the long run. There are many infections, such as gram-negative bacteria, klebsiella and E. coli that affect urinary infections as well as PVL-SA-Panton-Valentine leukocidin positive staphylococcus aureus-which is an infection that can affect young, healthy people, causing necrotising pneumonia and can kill in a few days. There have been improvements in MRSA and C. difficile in hospitals, but controlling infections needs constant attention to detail. We should never get complacent.
I have great admiration for the front-line nurses who go out and find homeless and hard-to-reach people at risk of tuberculosis and work in prisons with a multitude of infections, including hepatitis B and C. Drug-resistant TB must be kept under control. These resistant infections, which are expensive and hard to
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I hope that this debate will help to show our appreciation for front-line nurses, who need to have the highest standards to keep the NHS on top of the job.
12.25 pm
Lord Hunt of Kings Heath: My Lords, in thanking the noble Baroness, Lady Emerton, for her splendid opening to our debate, I declare an interest as chair of the Heart of England NHS Trust and as a consultant and trainer for Cumberlege Connections. I also acknowledge my noble friend Lord MacKenzie on the Front Bench. I suspect that what he does not know about nursing is not worth knowing; it is very good to see him there.
This is a very timely debate. We all agree that the quality of nursing care is fundamental to the quality of the patient experience. However, we are presented with a paradox. On the one hand there have been huge advances in the nursing profession over the past 20 years. There has been the move to it being a graduate profession. Nurses have taken on much greater responsibility. There is complex care and specialist nurses, in both hospital and the community, as the noble Baroness, Lady Jolly, so vividly informed us. I think also of midwifery. If the noble Baroness, Lady Cumberlege, were here, she would be able to talk about changing childbirth and how the profession was encouraged to take on a huge leadership role. The public have welcomed the increased responsibility that nurses have taken on.
At the same time there has been a mounting concern about basic standards of care and issues to do with hygiene, the feeding of patients, nutrition, dignity and even face-to face contact. This has been reinforced by several reports from unannounced visits and the CQC over the past few years. There have been any number of investigations of concerns about what seems to be a falling off in basic values of care. What is the reason for that? My noble friend Lady Warwick convincingly demonstrated that the old canard about modern nurses being "too posh to wash" just does not stack up. However, there are a number of questions that one might ask. There is a real question about whether nurse training is too focused on academic performance rather than on practical nurse training.
I also wonder whether the drive for specialist nurses and modern matrons has removed too many experienced nurses from the ward or the equivalent within the community. Has the lack of regulation for healthcare assistants led to patchy and inadequate care in some places, despite the undoubted dedication of many of them? We need some serious thinking about how to enhance quality overall and the standards of basic care that nurses give. Certainly, in my own trust a lot of thinking has gone into the quality of nurses. I claim no credit for it. While we do not have matrons in starched caps, we certainly have visible chief nurses
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Another thing that we have done is to develop a robust measurement of nurse standards by polling 400 patients a month, looking at the results, reporting to the board and trying to identify any problems with nursing care. The third thing that we have done is to develop VITAL-virtual interactive teaching and learning. Essentially, it assesses all nurses online for their knowledge of best practice in fundamental care. This covers, for example, nutrition, falls, privacy and dignity and pain management. Since the summer, 60 per cent of our trust's workforce have achieved 100 per cent in that online examination. Our intention is that from next year all newly qualified nurses and midwives will have to achieve 100 per cent within six months or they will not get the substantive contract. We also expect our nurses and midwives to sign up to a code of values and behaviour. We are introducing a badge for our nurses which will be achieved only if they get 100 per cent in the online test, sign up to our values and have evidence that they are putting those values into action. The noble Baroness, Lady Emerton, will certainly remember the badge, which nurses wore with pride. It showed where they came from and who they were; for example, the Tommy's nurses. We need to get some of that ethos back into the health service.
We have done a lot but there are a lot of issues around the training and education of nurses. I do not disagree with the requirement for nurses to have a degree. I do not think there is any argument about that. However, we have thought about how a foundation trust could be much more involved in nurse education and in supporting students in practical nurse training. We wanted to facilitate a practice-based model built around the trust which promoted our core values but adhered to national standards and the curriculum as laid down by the Nursing and Midwifery Council and with appropriate academic accreditation. It is fair to say that our proposal has not met with universal acclaim. Indeed, I feel that all the establishment bodies concerned with nurse training and education have put a real dampener on this. We have been accused of turning the clock back to the old schools of nursing. That is a bit unfair to some of the old schools of nursing because they were pretty good. However, we are not trying to do that. We seek to facilitate a more practical-based nurse education degree, which would have degree status but would be built much more around the hospital and its values. I do not think that this discussion is at an end. I believe that we will soon have a new chief nursing officer to follow on the excellent current CNO Christine Beasley, if one has not yet been appointed. This must be one of the main
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The noble Viscount, Lord Bridgeman, and the noble Baronesses, Lady Jolly and Lady Masham, were right about the role of senior sisters, or their equivalent, in the community. We need to empower them to lead. That means they have to have control of the budget so that whoever is providing the cleaning or the food, whether it is directly employed people or contract cleaners, none the less when the senior sister wants something to happen there is no question but that it happens. We need to give our senior sisters much more confidence and support to take on a leadership role. We need to go back to the days when doctors were a bit scared of the senior sister because she is in charge and she is the person on whom the patients depend for the overall quality of care. Making our senior sisters supernumerary so that they can focus entirely on leadership and management will cost us £1.6 million. It is a challenge to find the resource to allow them to focus much more on leadership. The problem with being drawn back into being counted as one of the qualified nurses on wards is that they then get so focused on caring for patients that they just do not have the time to carry out the leadership role that is required.
I urge the noble Earl to take account of two further points. My noble friend Lady Warwick talked about the lack of UK research in relation to basic nursing standards. The noble Earl will not be surprised to hear that there is an issue with regard to the amount of money spent on research into nursing. I know of the efforts made by the department over the years to give a boost to the amount of money spent on research in relation to nursing but clearly we need to go somewhat further in that regard. We probably need to have more academics who can focus on research.
With regard to healthcare assistant regulation, the Government's response is to have a voluntary register. I suspect that there will be a halfway house and that it will not be long before some NHS organisations will say, "You can't be a healthcare assistant with us unless you register voluntarily". I hope that training programmes will be set up but, for the reasons that the noble Baroness, Lady Masham, has given in terms of safeguarding the public, the argument for regulation is becoming ever more persuasive.
I hope the noble Earl recognises that the number of nurse training places should be determined by Ministers. If he devolves that issue, he will find that in times of financial difficulty the number of training places will be cut. I would give much more discretion to the NHS locally to determine arrangements with universities regarding the provision of graduate education for nurses. However, history tells us that the moment the department relinquishes control of the number of training places, the health service does the wrong thing. I know that we are debating the tension between national leadership and local discretion, but national leadership is required in some areas, and this is one of them.
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12.36 pm
Baroness Browning: My Lords, it is a great pleasure to follow the noble Lord, Lord Hunt of Kings Heath, with whom I have debated many issues in this Chamber.
I agreed with every single word that he said in this debate. I stand in awe of what he has done in his trust. He recounted the list of things that had been implemented, not all of which seemed to need an awful lot of money, although I understand what he said about education and training. You wonder why such practice cannot be rolled out around the country and why exemplars cannot be picked up rather than having trusts that try to reinvent the wheel, struggle or in some cases attract rather adverse headlines, as we have seen in recent years.
I had the great privilege to serve as a Member of Parliament for 18 years in another place. During that time I had the pleasure of working with and for nurses and midwives in my constituency, many of whom came to see me to discuss the problems that they encountered in their work. Sometimes they came individually and sometimes collectively. I pay tribute to the work that the profession does. There are people out there who go that extra mile. As patients or relatives of patients, we should all be extremely grateful to them for that. I know that I am.
However, as has been mentioned by other speakers, healthcare, which includes the nursing profession, has been the subject of some very worrying and adverse headlines, not just in recent weeks but for a long time. Some eight years ago in a debate in another place I raised concerns about nutrition and fluid intakes based on my personal experience of having an elderly relative in a hospital. It seems to me that these things have gone on for a very long time. Mencap still has concerns in this regard. Three years ago it published a report, Death by Indifference, which discussed people with learning disabilities who had died on hospital wards not through disease but through neglect. That is an indictment of us as politicians and of our nation. Members of the nursing profession and others involved in healthcare must feel that very keenly when they see and read about what is happening.
As I listened to the noble Lord, Lord Hunt of Kings Heath, I wondered how hard it would be to make best practice universal if there was a political will and a professional will in all parts of healthcare to look at what works and to implement best practice. I realise that budgets come into these things and that there are always differing opinions on how to do things. However, we are starting to see some common themes coming through, not least in the reportFront Line Care, which the noble Baroness discussed. There is a common theme in this report. There is great confusion in the healthcare system, particularly in hospitals, and we as patients are also confused. It is quite possible to go into a general hospital ward and come away still not really knowing who was in charge. It is the uniforms, it is the way people conduct themselves. It is not that people are not doing their job, but you cannot always say who is in charge.
The heading on page 60 of the report says, "The Proliferation of Roles and Titles", and I would add uniforms to that. At one time I thought I understood
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- "especially doctors ... were often unclear about what skills and competencies they could expect from individual nurses and support workers, exacerbated by the plethora of job titles and role descriptions".
It is bad enough that I as a patient was confused, but the fact that doctors are also confused tells us that something needs to be sorted out, and urgently.
Much more seriously, if doctors do not know what they can expect from these different job titles and uniforms, and if the nurses themselves have to delegate-I will come on to delegation in a moment-it is no wonder that there are problems and that some of them become systemic. I say to my noble friend, for whom I have great respect for the work he does on the Front Bench, that these problems are now systemic and need to be treated as a matter of urgency.
Frankly, we do not need another five years of reports and anecdotal evidence. It seems pretty obvious that some people are now overcoming these problems-the noble Lord, Lord Hunt, explained what happens in his trust-and this could now be rolled out. While I understand the need for localism and local decision-making, the Government have to take some leadership in making sure that this is rolled out and that they act as the catalyst to ensure we do not have the same debate in five years' time.
I return to the subject of nurses and the nursing profession. I agree with noble Lords who have said that it does not necessarily follow that because someone has a degree in nursing, they lack compassion. That is a rather terrible thing to say. However, there is a question about the structure of nursing, which yet again is picked up very well in the report on page 87, under the part entitled "The Way Forward". The report says:
"There was much comment on the style of leadership needed for the future. 'It's to do with whether we're transactional (you will do this, that or the other-talking down to staff)"-
the Hattie Jacques scenario, I suspect, although a lot of people would quite like to see a few more Hattie Jacques on the ward-
The report goes on to talk about mutual respect, not working in silos, and working as a team. Anyone who has worked in any large structure, whether in healthcare or elsewhere, will recognise those two different styles of management, although I have to say that it does not have to be one or the other. Leadership is about taking difficult decisions and about looking holistically across the whole. I quite agree with colleagues who have said today that those in charge of a ward should also have the authority to deal with nutrition and cleaning. I remember a debate in a German hospital, where the wards were absolutely spotless, about whether cleaning services should be contracted out. The question was asked, "How do you make sure that these wards are so absolutely spotless?". The reply was that the
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Nurses also have to delegate. I was very interested to hear Tony Hazell giving evidence on Tuesday to the Health Committee, which is holding an inquiry into education, training, and workforce planning. He said that there will be more training, both for nurses and for healthcare workers to whom nurses delegate. From this report, it is clearly rather important that everyone in the structure knows and understands their role, and that people are prepared to delegate so that they are not working in silos. In-service training is also important for nurses working in hospitals, out in the community and elsewhere, as well as for those who are not nurses but who work in a supportive role. If such ongoing training were in place, we would not get the horrendous stories, which I have personally experienced on more than one occasion and with more than one person, of food being left at the end of the bed for someone who cannot access it. In-service training and education throughout is important, and it will also help nurses.
Finally, it is important that where there are serious problems, nurses should be able to report colleagues in a structured way. It is called whistleblowing-a horrible term-but in my experience, where really good nurses experience this and hit the buffers in trying to report problems, too many of them leave the service. They find it just too difficult and too unpleasant. We have to build that into the structure when we come to reform these services.
12.47 pm
Lord Young of Norwood Green: My Lords, I, too, thank the noble Baroness, Lady Emerton, for initiating this debate and congratulate her on a superb contribution. I enjoyed the history of nursing but must admit that I felt that one name was absent-especially as we are talking about front-line nurses-and that was Mary Seacole, who brought a different approach, though a very interesting one, about the same time as Florence Nightingale. I see that I have not transgressed because the noble Baroness is nodding. I am relieved that I have got my history right.
I enter this debate as a lay person, but I cannot help thinking that if Benjamin Franklin were alive today and living in the UK, he might be saying that there are three things that are certain: death, taxes and-whoever we are, at some point in our life-being impacted on by the National Health Service. Of course, the unfortunate fact is that as we gradually mature-I do not say get older; in the House of Lords we mature-we experience that impact. Last year I spent a week in an NHS hospital having a large lump of titanium inserted in to my hip. It was largely a very good experience. It was fascinating being in the ward, looking at the atmosphere there and the nature of the people who treated me. As has been said, some were absolutely superb: they had empathy, compassion and all the things that you want. Others, I could not help feeling, needed to be taken to
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When it is good, it is really good. I noticed this during that week. There were some ward sisters who came on and would do anything; never mind "too posh to work", they would do any job whatever. They were a brilliant example of leadership at its very best. There were others with whom I felt that it was not quite right. The worst example that I saw was when the elderly woman with suspected pneumonia in the bed next to me was getting in to that panicked breathing mode. In a plaintive voice, she said, "Help, nurse. Help", and a young nurse who was sitting at a computer turned round and said, "Someone will be along in a minute". I had difficulty in restraining myself at that point and fortunately someone did come along, but why did that nurse not get off her backside and do what she should have done, which was to respond to the woman while holding her hand? It is a matter of changing the culture-something that has already been referred to. I hesitate to bring up the worst examples but, if we do not have an honest and frank debate, we will not really address the issue.
However, as I said, I have seen some wonderful examples. My wife is currently being treated for a serious kidney condition and the renal ward at Hammersmith Hospital is absolutely brilliant. I reckon that the senior ward sister there-Sister Nicola-would be able to solve most of the problems in the National Health Service if only we could clone her. She is marvellous and empathetic, and the ward runs like clockwork, and so there are some absolutely brilliant examples.
My noble friend Lady Warwick rightly condemned the generalisation that takes place in the media by implying that, if you have a degree as a nurse, somehow you cannot undertake basic nursing tasks. I, too, reject that-it is clearly wrong. However, we have to make sure that the training for people who study for a nursing degree is right. As I understand it, they should spend 50 per cent of their time on the wards. I should be grateful if the noble Earl, Lord Howe, could confirm whether that is the case when he responds. Ward experience under the watchful eye of trained sisters is vital.
My noble friend Lord Hunt, who seems to have captured the ground in progressive approaches to the development of nursing, gave us some very useful pointers. Why do nurses not have something equivalent to the doctors' Hippocratic oath? My noble friend was absolutely right to talk about a code of values. That ought to be taken on board and be a part of the national scheme. Knowing who is in charge and has authority is important. Going back to one of the best examples that I had experienced, when I asked Sister Nicola what her qualifications were and whether she had been in the nursing profession for a long time, I discovered that she actually had only a diploma. I am not arguing against degrees but, with my passion and enthusiasm for apprenticeships, I argue that there should be a vocational route into nursing. Interestingly,
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The noble Baroness, Lady Browning, said that there are a number of practical things that can be done-my noble friend Lord Hunt told us about some of them-and that we do not need another five years of research to encounter what we know to be proven good practice. I hope that the noble Earl, Lord Howe, will be able to assure us that spreading best practice will be one of the Secretary of State's key roles. It is not just about money; there is a real debate about staffing, although I do not want to go into that. Obviously if people feel under real pressure, that is going to create problems. I do not particularly want to explore that side of the issue but spreading best practice, as a key part of developing the health service, seems to be fundamental. Surely it would be a cost-effective, value-added method of improving the health service.
I have one or two points to make in conclusion. The noble Baroness, Lady Browning, touched many buttons when she talked about the confusion over uniforms. I absolutely echo that. You think, "That one's in blue, that one's got blue with spots on and that one's in pale blue". Sometimes it is also really difficult to distinguish healthcare assistants.
There is a question over whether healthcare assistants should be regulated. I tend to feel that, because they have become so important to hospitals and community care, the one thing that we should insist on is a requirement for basic training. That should not be an option. Perhaps a code of values, which my noble friend Lord Hunt suggested in relation to nurses, should also be adopted for care assistants.
A number of contributors said that it was important to make sure that those in charge of wards have authority. I have recently been in hospitals where the wards have been spotlessly clean. That is one part of the problem in wards but it is not the only one-noble Lords have also referred to the feeding of patients and so on.
I am conscious of the time but I should like to make a final point. I think that it was on the "Today" programme on Radio 4 this morning that I heard a former nurse speaking about whistleblowing. I do not like that phrase either, because it should not have to happen. The right management environment should encourage people, as part of working in a team, to explore the strengths and weaknesses of their work on a ward. They should be able to say, "How can we work together? If there are problems, I should be able to feel that I can go to my immediate manager and have a frank discussion". It is important to ensure that the right processes are in place to enable nurses to feel confident enough to do that.
In conclusion, I feel privileged to have had the opportunity to take part in this debate and I look forward to hearing the noble Earl's response.
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12.57 pm
Lord Patel: My Lords, I note that I am the only doctor speaking in this debate. Noble Lords are right: doctors do as matrons tell them. Therefore, when my noble friend Lady Emerton-the matron-said to me, "You will speak", I did not argue, but I am very pleased to be able to do so and I thank her for the opportunity.
As most noble Lords know, during my fruitful life my specialty was maternal foetal medicine. I worked in a team that looked after mothers whose pregnancies were complicated by other medical conditions or who developed serious complications during pregnancy or labour. I pay tribute to the most dedicated nursing workforce with whom I had the privilege to work-midwives and specialist neonatal nurses. They were the key members of the team and prevented not only deaths but handicaps among the babies who were born either prematurely or with difficulties, or whose mothers had a difficult labour. They are the most skilful nurses with whom I have ever worked. I still go to my hospital occasionally. I walk through the labour and delivery room and get the usual comment: "Have you come here to work or to drink our coffee?". I have the coffee, as I do not think that I would be allowed to work. I am going to talk mostly about the current state of affairs in midwifery and neonatal nursing.
We currently have a shortfall in England of between 4,500 and 5,000 midwives. This is partly because of a fall in recruitment but it is also related to an increase of 22 per cent in the number of live births over the past two years. There are now 690,000 births per year in England. Another problem is that the midwifery workforce is ageing. Half the workforce is aged between 45 and 55, and therefore recruiting a younger workforce is extremely important. Not only that, there is a change in the way in which midwives work. Their work has become more complex because of older mothers. There has been a 71 per cent increase in 40 year-old mothers and a 24 per cent incidence of obesity in pregnancy, both of which lead to higher rates of complications in antenatal care and in labour.
There is also a reduction in the overall budget. In 1997-98, the maternity services budget was 3.1 per cent of the total NHS budget. Although the sum might have gone up in total, it was 2.46 per cent in 2010. There is a serious issue of recruitment of midwives and an increase in maternity services. I know that the Government recognise the problem. Even before the election the Prime Minister, as Leader of the Opposition, writing in the Sun pointed out that midwives were,
He promised that when in power, the Government would increase the number of midwives by 3,000. Unfortunately, that has not happened.
I congratulate the Government on the issue of training. They have committed to maintaining the same number of places for student midwives in the 2011-12 academic year as there were in 2010-11, which was a record high. This is welcome as it will help to address the two issues of the midwifery shortfall and the ageing midwifery profession, provided that there are jobs at the other end of the process. Recruitment ought to be part of it.
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Last week the Royal College of Midwives published its State of Maternity ServicesReport 2011, which makes several good points. The key ones suggest steps to address the problem. One is to increase the choice of place of birth-I know that the Government are keen to allow mothers to have a choice-such as midwifery-led units and home births. Births in these settings require less midwife time, and in low-risk pregnancies outcomes are not affected. Other suggestions include: the appropriate deployment of properly trained and supervised maternity support workers to do non-midwifery tasks; a guarantee not to cut midwife training places; and encouraging the health service to increase recruitment and meet the target of 4,000 more midwifes.
There is clear support for more midwives. A recent public e-petition to Parliament calling for the Government to recruit an extra 5,000 midwives has already been backed by 20,000 people. I hope that after today's debate it might increase to 2 million. I hope that I have made my point that there is a need to address the midwife shortage if we are to deliver quality care to pregnant mothers and newborns.
I turn briefly to the issue of neonatal nursing. As highlighted in the report published on 9 November by Bliss, a special-care baby charity, one-third of neonatal units in England are cutting their nursing workforce, stopping recruitment or downgrading posts. Referenced against the Department of Health's toolkit for neonatal services, there is a shortage of nearly 1,200 neonatal nurses. Care of the neonates, both premature and following neonatal surgery, is highly skilled, intensive work, and outcomes for those vulnerable babies, including mortality rates, are directly related to skilled nursing care around the clock. Cuts in training and education budgets have led to a shortage of qualified specialist neonatal nurses. We need commissioners and providers to implement NICE specialist neonatal care quality standards. In future we will rely a lot more on NICE quality standards to drive up quality and outcomes in the health service. If they are not implemented-as they clearly are not, in specialist neonatal care- improvements will not come about.
The Government want a reduction in perinatal and infant mortality. Delivering care to neonatal quality standards will go a long way to achieving that. I look forward to the Minister's comments on both maternity and neonatal services.
1.06 pm
Lord Ribeiro: My Lords, I apologise for speaking in the gap without giving notice, but I could not let the noble Lord, Lord Patel, give the impression that he was the only doctor here who was prepared to speak. I thought that I would share some thoughts on my view of nursing, which I have to limit to my own special interests of surgery as they are the only group of nurses I know anything about.
It is interesting that reference was made to the Salmon report, which I think was produced in 1968 when I was a fairly young junior doctor in the Middlesex hospital, which sadly no longer exits. We had a matron, wing sisters and ward sisters, and there was no question about who was in charge. There was leadership right down to the ward level, and the important thing about
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One of the things that has been said about doctors is that they have treated nurses as their handmaidens. It may be said that doctors have been resistant to seeing nurses progress, and we have had a long debate about training, education and diplomas, which I shall not go into. But the opportunities that opened up for nurses after Salmon did provide nurses with a way to move into management and other areas. The advantage for nurses is that their opinion and advice has influenced medical care over the past 40 years that I have been in medicine, and much of it to the good. The downside has been that we have created another pathway for nurses to go other than the ward. Therefore, talented nurses may have wanted to stay on the ward but if they wished to progress and improve their salary status, they had to go sideways into management. That is where some of the problem has emanated from. We must look at ways of remunerating and keeping nurses who want to stay on the wards to do so.
I shall not speak for long but I want also to make a point about teamwork-nurses and their contribution to the team function. As a surgeon, like the noble Lord, Lord Patel, I know that we work in a close team. Our main team is the ward staff and ward sister who look after our patients. In my case the ward sister would tell me through the grapevine when my junior doctors were not doing all that they should. There is a big function for the ward sister, other than just looking after patients. In theatre, you have a close-knit team. Another thing that I regret is that in the old days many nurses would come along and observe what was going on in theatre and say that they would like to become theatre sisters. They were encouraged to go into it. Latterly in my time as a consultant, I found that fewer and fewer nurses were being directed to go to work in theatre. I think this is a great shame because we live in a world of multidisciplinary working, and it is important that nurses should be encouraged to specialise if they wish to.
Finally, I came back from Afghanistan recently, and in answer to the noble Baroness, Lady Masham, I have to say that the nursing teams in Camp Bastian are superb. Many of them are volunteers from this country, and their contribution to the war effort in Afghanistan has to be noted and applauded.
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1.10 pm
Lord MacKenzie of Culkein: My, Lords, we all owe a great debt of gratitude to the noble Baroness, Lady Emerton, for securing this important debate on front-line nursing today. It has been a very well informed debate. It is not very often that we have the opportunity to debate nursing in this House, so the debate is to be doubly welcomed. It comes at a time when the nursing profession is, to coin a phrase, getting it in the neck. As my noble friend Lady Warwick of Undercliffe said, not a week goes by but there are reports of poor care with a lot of armchair analysis of where it is all going wrong. There are justifiable concerns which have to be addressed, and I will come to them shortly.
Like the noble Baroness, Lady Emerton, I am a nurse who is no longer on the effective register, and I have not been for the past 10 years to so, but because of that I want to start from this side of the House by saying something in defence of the nursing profession. The vast majority of nurses, and midwives too, are good and safe practitioners. They provide good quality and safe care. They are highly skilled. They are involved in research and all sorts of things that could have been only dreamt of in my early days as a nurse. Good work does not get publicity. The noble Baroness, Lady Jolly, reminded us of the good work done by Macmillan nurses and hospice nurses, and the noble Baroness, Lady Masham, and the noble Lord, Lord Ribeiro, referred to nurses who join the military reserves, spend six months in Camp Bastion, then come back and continue their remarkable work in the National Health Service. Good work is done by specialist nurses, such as stroke nurses or community psychiatric nurses, to highlight just a very few. Good things do not get publicity; bad things do. The image of the nursing profession is suffering as a result of recent publicity, some of it rather damning, about the quality of care in a number of settings.
In my experience, morale has its ups and downs, and now it is on the way down but at least until now the image of nursing had always been good. Morale is now being hit from a number of areas including the growing public perception that nurses are not capable of compassionate care, the two-year pay freeze and pension issue, the downgrading of posts and the actual and forecast staffing reductions coming from the Royal College of Nursing and UNISON. As we have heard today, that is not just hyperbole from staff organisations. The noble Lord, Lord Patel, told us stories about special care baby units and the number of neonatal nurses who are being downgraded while in post. We are getting the same story from the Multiple Sclerosis Society that a significant number of posts are being cut.
It became really too much when a leader in last week's Sunday Times said:
"One reason for the government's tough austerity programme is that ... Labour poured more money into the National Heath Service ... and the number of nurses increased by a fifth".
That is going too far. Poor morale is not conducive to happy nurses, and no Government can ignore it for very long. I think a match may have been put to a slow-burning fuse with the prospect of even heavier cuts, 1 per cent pay maxima and possibly different
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The report of the Prime Minister's commission on front-line nursing, set up by my right honourable friend Gordon Brown, has much to commend it. The noble Baroness, Lady Emerton, was, as she reminded us, a commissioner. The recommendations of that commission, if implemented, point the way forward on many of the issues that need to be addressed for the future. The present Government welcomed the report. They say that it does not go far enough but, at the same time, they say that it has to be looked at in the light of the present economic climate. That might be a contradictory position.
Staffing levels are always an issue in nursing. We heard about them yesterday in the debate on mandated levels and ratios, and we know from research that inappropriate staffing leads to poorer care and higher mortality. In response to amendments yesterday, the Minister told us about the safeguards that will be in place, but most of them are already in place yet have not prevented the problems, for example, in Mid Staffordshire, and when the CQC gets involved, it is, as was highlighted yesterday, usually too late.
There is much mythology about the so-called good old days. The press are forever hankering after matron, but know nothing about the science and art of nursing. What is not a myth is the fact that basic or essential care was better. I speak as a fascinated observer and recipient during a recent six months' hospitalisation. I should have been in for one night, but ended up staying for six months. My experience was that most technical skills were excellent, although staffing levels and ratios outside intensive care and high dependency were not always good enough. Essential care was not always as good as it could or should have been. The care that used to be delivered by enrolled nurses, student nurses and pupil nurses is now delegated to some 303,000, I understand, healthcare assistants or support workers who fulfil many different nursing and midwifery roles. I am told that there are some 120 different job titles for support workers throughout the National Health Service. If that is true, find it astonishing. As was said yesterday, there is too much variation in the quantity and quality of training available for support workers. That needs to be improved and to be done to a national standard agreed with stakeholders. Scotland has already done this, and Wales and Northern Ireland are looking to follow.
Much of the care that is delegated to healthcare assistants is hydration, nutrition, pressure area care, intimate care, oral hygiene and keeping the patient clean and dry. We used to call that nursing care but, to my regret, it is often now dismissed as social care. It is nothing else but essential nursing care, and if it is not done, and done properly, then we have lost sight of what we are about as a profession. Healthcare assistants increasingly do more than essential care. They do
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Can we get rid of the confusing titles? Patients are entitled to know who is looking after them. The noble Baronesses, Lady Masham and Lady Browning, and my noble friend Lord Young mentioned uniforms. They are confusing. Patients have no idea who is looking after them. The whole of the profession is suffering because the basics are not always being attended to. This is, I am convinced, due to incorrect staffing levels and training, education and organisational cultural issues. It is also to do with societal attitudes to the elderly, which is not peculiar to the National Health Service. The National Health Service cannot cure society's ills, but it needs to get a grip and sort this matter out internally.
There are more changes to come. Nursing in England is to become a wholly degree-based profession, which is right. But perhaps I may pick up on the point made by my noble friend Lord Young that there needs to be a wider entry gate. There is always the fear that when a profession becomes wholly degree-based, it cuts out the possibility of a number of people who would make excellent nurses getting entry to that profession.
Good selection of potential students is essential. Recently, we have heard quite a bit about nurses not being fit to practice when they emerge from universities. I do not know whether enough nursing input goes into that selection but, if not, it should do. We also need to deal with clinical practice and relate it to theoretical content, and we need to get it right. My noble friend Lord Hunt of Kings Heath has spoken at length on this point and I agree with him entirely. I do not think that there is anything wrong with a practice-based model and I hope that those discussions are not at an end.
Protection of the public should be effective, all the more so given the cost-driven trend for employers to substitute trained nurses with support workers. That brings me back to regulation, at least of those who are delegated duties by trained nurses. The Nursing and Midwifery Council, the Royal College of Nursing, UNISON, the Queen's Nursing Institute, the health committee in another place and, not least, healthcare assistants themselves want statutory regulation. The Government do not agree. They want assured voluntary registration. Some regard this as a small step in the right direction. It is small step but we do not think that it goes far enough. However, we will come back to that debate in the near future under the Health and Social Care Act.
Perhaps I may return to the Prime Minister's commission on front-line care. I hope that the Minister will give us some detail on what the Government plan to do with each of the recommendations. I appreciate that that is a tall order, so perhaps he could write to us.
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We have heard a lot in this debate about the responsibility of senior nurses. I agree entirely that they need to be given back the authority that they had. On corporate responsibility, as we have heard, recently Sir David Nicholson told a conference of senior NHS staff that many of its employers had no idea of how many nurses they have in the hospital or on a ward at any one time. A hobbyhorse of mine is the return of the ward sister. That responsibility must be restored and properly defined. Like the noble Baroness, Lady Emerton, I am passionate about nursing. I look forward to what the Minister has to say. Again, I thank the noble Baroness for giving us the opportunity for this debate.
1.22 pm
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, on occasions like this, I reflect on how lucky we are in this House to have the noble Baroness, Lady Emerton, in our midst. She has allowed us to appreciate once again why she is such an unquestioned authority on this crucial subject of nursing care. I, for one, am very grateful to her.
The wording of her Motion is of course carefully chosen. Front-line nursing-in acute settings, in the community, in schools and in people's homes-is a part of all our lives and has always been an essential element of patient care in the National Health Service. Patients are clear about what good nursing care should look like. They want to be confident that their nurses are knowledgeable, safe and competent. They expect their nurses to be caring and compassionate. They want to be treated with respect by nurses who genuinely care for them and about them.
We in Government are also clear about what we expect from a front-line nursing workforce. I cannot better the description offered by the noble Baroness, Lady Warwick. We expect high-quality, safe and knowledgeable care for all; we expect dignity and compassion for all; and we expect nurses to make the most of each and every interaction they have with patients to improve their health and well-being, and their experiences of care.
What makes a good nurse? The first requirement is a point raised by my noble friend Lord Bridgeman. We should attract people into the profession who not only have academic ability, but also have the right values, attitudes and behaviours. Education commissioners expect universities to demonstrate that their recruitment processes embrace this approach. Employers will also look for this as part of their selection and recruitment processes when they are helping to interview potential students and are appointing registered nurses. Getting this right at the start will help to reduce attrition and maximise the resources that we put into nurses.
The second requirement, as our debates on the Health and Social Care Bill have amply demonstrated, is that we educate and train our nurses well. The Nursing and Midwifery Council undertook a comprehensive review of pre-registration education and published new standards
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The next requirement is to enable nurses to nurse. That means doing what the noble Baroness, Lady Masham, talked about so compellingly: finding ways to make sure that we keep senior, experienced nurses beside patients delivering hands-on care and not filling in endless piles of paperwork, which are sometimes of marginal usefulness. That is why we are committed to reducing bureaucracy and empowering our nurses as clinical leaders. The NHS institute's productive series is helping nurses to reduce unnecessary and wasteful practice at the point of care, which is freeing up nursing time to be spent on essential tasks, such as providing assistance with mealtimes and carrying out interventions to prevent pressure ulcers and falls. Any good nurse will tell you that spending more time with the patient facilitates a better and more timely patient assessment, thus enabling the nurse to spot signs of deterioration or to pick up on small but significant things that a patient often will not think to mention. That is why my officials are working with the NHS institute to explore ways in which areas that are not yet embracing the productive series can be identified and supported with implementation, thus allowing the spread of best practice, about which the noble Lord, Lord Young of Norwood Green, spoke.
A phrase that I have learned recently is "essential rounding", a system that sees nurses doing planned rounds every one to two hours to check on patients and to deal with any concerns. We are pleased to see nurses embracing that concept. Feedback about it from patients and nurses is very positive, with some studies seeing a reduction in falls and improvement in patient experience since implementation. In fact, a plethora of best-practice guidance is available. But central initiatives can take us only so far, which is why effective nursing leadership at the front line is so important. Matrons and senior nurses are role models and they are pivotal in developing the culture of care in their clinical areas. Through the standards they set for others to follow, to monitoring the performance of individual nurses, they ultimately make the difference between good and bad care.
I welcome the work of the NHS institute in developing a clinical leadership competency framework which will help develop patient-centred nursing leadership. The noble Lord, Lord MacKenzie, whom I welcome to the Front Bench, was right that the vast majority of nurses are extremely professional, care deeply about their patients and do a tremendous job, often under very difficult circumstances. But, at the same time, the
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However, I would say to the noble Lord, Lord MacKenzie, that I do not think that it is right simply to say that this is because of poor staffing. The CQC dignity and nutrition inspections found many examples of excellent practice where staffing was not ideal and cases of poor nursing care where there was a full staffing complement. We are hearing more and more concern from patients and nurses themselves about inadequate staffing levels and inappropriate use of support workers. As I said in our debate yesterday, setting safe staffing levels is not an exact science. These decisions are complex and they are best made by local clinicians and managers on the ground, who understand the needs of their patients. As noble Lords are aware, there is guidance available from the RCN and others to assist clinicians and managers in setting safe staffing establishments.
This same guidance is used by the CQC when determining whether providers have enough suitably qualified, skilled and experienced staff. The CQC can take tough and independent action when an organisation is not taking appropriate steps to ensure that there are sufficient numbers of suitable staff at all times. The noble Baroness, Lady Emerton, mentioned Anne Marie Rafferty's research. I would be pleased to look at that research in detail and I will ask the Nursing and Midwifery Professional Advisory Board to consider it and report back to me early in the new year.
Much of the concern around nursing in acute settings has been related to inappropriate delegation by nurses to healthcare support workers. Wherever there is a multidisciplinary team of regulated professionals and unregulated healthcare workers, appropriate delegation and supervision is vitally important. This is an area ripe for formal review. We very much welcome the NMC's plans to update its guidance on delegation so that nursing staff know how to do this safely and are clear that they retain responsibility for their actions. We have also asked Skills for Health and Skills for Care to accelerate production of a code of conduct and recommended core training for healthcare support workers and adult social care workers in England. We expect work to begin by April 2012, with the aim of delivering outputs ahead of the establishment of an assured voluntary register, which could be operational from 2013 onwards.
Nurse leaders, managers and trust boards must take staffing concerns seriously and, where staffing is found to be an issue, they must take immediate action. In the new world of the NHS, there will be two watch words for commissioners: outcomes and quality. This
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Safe and effective care has several strands to it, all in the direct gift of nurses. Noble Lords may be aware of the QIPP safe care work stream quality improvement programme-the safety thermometer-which aims to focus nursing attention on four areas of harm: falls, blood clots, pressure ulcers and catheter-related urinary tract infections. We have published the 2012-13 operating framework with strong messages about reducing harm in these areas, making sure that these are firmly on trusts and commissioners' agendas.
My noble friend Lady Browning spoke of the need for government leadership and she is right. We are making sure that the nursing contribution to quality is being championed at the very centre of government. The SHA chief nurses are leading the nursing contribution to quality improvement at the front line through the energising for excellence quality framework. Much of the success of the quality framework will depend on transparency and, as part of our transparency agenda, NHS North is working towards local publication of nurse-sensitive metrics in areas such as falls and pressure ulcers and is also exploring how best to include patient and staff experience data. The patient experience is absolutely centre stage as we set about measuring the quality of nursing care. Ensuring that patients have a positive experience of care is reflected in the NHS outcomes framework that the new NHS Commissioning Board will use to hold the NHS to account for what it delivers. Everyone who works in the NHS has a role to play in ensuring that patients have a good experience. It is not optional, and it is not "someone else's job". The task is to make listening, understanding and responding to patients' views as commonplace as acting upon clinical audit data, patient safety data or financial data.
Nurse training has, unsurprisingly, featured prominently in this debate. The noble Baroness, Lady Warwick, raised the issue of continuous professional development. Later this month, the Government are publishing our detailed proposals on education and training that will describe the arrangements for continuing professional development, which we recognise is of great importance. My noble friend Lady Jolly spoke about the role of specialist nurses and her concern about downgrading roles without due regard to patients' needs. I agree that service planning has to put patients firmly at the centre. The Government acknowledges the important role of specialist nurses in improving health outcomes and patient experience. In the end, local organisations must have the freedom to determine the skill mix of their clinical teams. Commissioners, clinicians and trust boards have to work together to ensure that the workforce is capable of meeting the needs of patients and that they have access to continuing professional development.
My noble friend also spoke about the introduction of end-of-life care standards, and I am happy to assure her that we will continue to work towards implementing the end-of-life care strategy.
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The noble Baroness, Lady Masham, spoke with her customary force about bringing back old-style matron. That resonated throughout your Lordships' Chamber, and there is no doubt that strong nursing leadership is essential at all levels for high-quality care. The noble Lord, Lord Hunt, was quite right about that. Directors of nursing and trust boards must set the culture for a hospital, and that includes a leadership style that challenges poor standards and creates an environment for high standards.
My noble friend Lady Browning raised the subject of whistle-blowing. It is very important that the culture of a hospital is right to enable whistle-blowing to happen. Leadership from boards has to set the tone for that. To whistle-blow does require great confidence and support. I believe that more of this will come because of the increase in graduate nurses.
All this has a direct bearing on the point made by my noble friends Lord Bridgeman, Lady Browning and Lord Ribeiro about cleaning. Nurses have a key role to play in ensuring that hospitals are kept clean. The infection control nurse, the ward sister and matron who set and enforce local standards are particularly important. The code of practice for the prevention and control of infections ensures that nurses are involved in all aspects of cleaning standards. The code provides that directors of nursing are involved in all cleaning contract negotiations, which is very important. Matrons have personal responsibility and accountability for delivering a clean safe environment for care.
The noble Lord, Lord Hunt, mentioned supernumerary sisters. The RCN has just published guidance on developing business cases to fund the supervisory status of the sister so she can exercise her leadership role effectively. The guidance is helpful, timely and above all very practical.
The noble Baroness, Lady Masham, spoke of the importance of district nurses-again, absolutely to the point. We acknowledge the enormous contribution of district nurses in helping people manage long-term conditions, keeping people out of hospital and ensuring people are able to access the resources they need, when they need them. We want to make sure that people go to hospital only when they need what a hospital can do. We see a much greater role for district nurses in the future, not a diminishing one.
The noble Baroness, Lady Warwick, and others mentioned the RCN Frontline First report. I do not want to dwell too long on this, but I have to voice some serious criticism about that report. The RCN's numbers are mainly based on an analysis of just 41 trusts. The trusts identified in the report have disputed the RCN's figures. The RCN has not offered commentary on the fact that some of these plans are about moving services out into the community to provide better care for people when and where they need it. We are not disputing that some trusts have reduced the number of staff-some have-although many of these are support staff and often it is being done through natural turnover. We do emphatically reject the conflated numbers that the RCN is claiming. I have got some chapter and verse in my brief, but all I would say is that it is up to local trusts to determine their workforce needs. We have made it clear that any reduction in clinical posts
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The noble Lord, Lord Patel, spoke about midwifery. The Government are not reducing the number of midwifery trainees. In 2010-11, 2,488 midwives training places were planned. A further 2,507 training places are available this year-that is a record high. The Government are committed to ensuring that we have the right number of trained midwives, especially given the increased number and complexity of births in recent years. This includes ways of supporting midwifery recruitment and retention to help local organisations which are able to commission the number of training places that they need. We have asked the Centre for Workforce Intelligence to undertake an in-depth study of the maternity workforce starting this year. This will inform the future commissioning of training places, including for midwives.
On specialist neonatal nurses, I took the points that the noble Lord made. The National Institute for Health and Clinical Excellence quality standard and the toolkit for high-quality neonatal services are valuable tools to assist NHS commissioners and providers in the provision of high-quality care for babies and their families. However, I shall take away the points that the noble Lord raised.
We have heard today from my noble friend Lady Jolly, among many others, about the opportunities for front-line nursing. Technology moves on, medical knowledge is constantly advancing and the members of our nursing workforce will need to keep abreast of these changes. But one thing that we know will not change is the importance of the care that nurses deliver; and the key role that nurses can and do play in improving quality of care, patient outcomes and their experiences of care.
Lord Young of Norwood Green: Will the noble Earl comment on my point about a vocational route into nursing?
Earl Howe: In the time available, I shall do so very briefly. Access to nursing is, as the noble Lord will know, already through quite a wide entry gate-through progression from apprenticeships, NVQs and access courses. Universities set the entry standards and do not always rely on A-level qualifications. However, it is important that students must be able to cope with degree-level study-it would be wrong to set them up to fail. However, we are aware that the entry gate about which the noble Lord, Lord MacKenzie, spoke needs to be as wide as reasonably possible.
It is patients who matter most. As a Government, we are committed to bringing about the improvements in front-line nursing care that patients want.
1.43 pm
Baroness Emerton: My Lords, I thank every single person who has contributed to this debate, which has covered a very wide area. Everything said was neither good nor bad, but was to be noted-as the title of the debate invited us to do. The debate has given us an
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International Development Policy
Debate
1.44 pm
That this House takes note of Her Majesty's Government's proposals for international development policy, including proposals on the situation of Dalits.
The Earl of Sandwich: My Lords, I am delighted to open this debate on international development. It is nice to see a few old friends present. There may be other preoccupations nearer home, such as the eurozone crisis or the recession, but I am asking noble Lords to look at the drama going on every day in countries suffering from poverty and injustice. I much look forward to the maiden speech of my noble friend Lord Singh, who knows a lot about this subject. I declare an interest having been associated for nearly 40 years with Christian Aid, mainly as a staff member and a board member, and having also worked closely with Save the Children, CARE and Anti-Slavery International.
The current director of Christian Aid, Loretta Minghella, said in a conference last week that,
"The scandal and outrage of 21st century poverty is wrong".
More than 1 billion people suffer from hunger or injustice, and the two often go together. According to Save the Children, chronic malnutrition affects 178 million children-one-third of all children under five in developing countries. Of these, 7.6 million died from malnutrition, ill health or other effects of dire poverty last year. The world's population continues to grow, being above 7 billion, and could grow by perhaps half as much again in this century. Yet the rate is slowing down with economic growth, and I believe that this planet has the resources to grow enough food and defeat hunger. We will further reduce the number of malnourished people provided we beef up support for small farmers in the poorest countries, and production and distribution are properly managed.
We in Britain are in the forefront of this campaign. It is my starting point that, largely due to the work of our voluntary organisations, the British public in their many forms have become much more aware of needs around the world. Thanks to our NGOs and church networks working overseas, aid today has enormous popular support, expressed in the manifestos of all the parties and leading to our ring-fenced aid budget, which is not surprisingly envied by other departments.
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Our official aid agency, DfID, has shown that it is second to none among OECD agencies, at least level with the Scandinavians, who have always had the highest reputation. I am certain that DfID will be able to spend its increased allocation up to the 0.7 per cent target, although there are real concerns that other government departments may poach some of the budget. No doubt the FCO and the BBC will find legitimate ways of using some of it for diplomacy and broadcasting because there is much common ground between them.
Yet despite DfID's successes, I doubt that the public can be satisfied with the progress of the UN and our aid agencies in meeting the millennium development goals, or that our successive Governments have done enough to eradicate poverty. Everyone knows that government money is wasted, especially those who have worked in non-government agencies. This is why the coalition has decided to review the aid programme and test its accountability, to make sure that every project is value for money. Later, I shall ask the Minister whether that is achievable.
I am glad that my noble and right reverend friend Lord Harries will speak about the situation of the Dalits, since he also served on Christian Aid's board. We are both well aware that a large proportion of India's poor, about 170 million, are from that community. Atrocities are committed against them every day. I have described previously the appalling inhumanity of many caste Hindus, some in senior positions, and the urgent need for India and Nepal to implement the laws that they have already made. FCO and DfID have entered a dialogue with New Delhi and some of the active NGOs. I hope that the Minister will update us on that dialogue.
I shall not deal with multilateral agencies or the European Union today, but I hope that someone will. They were well covered by the noble Lord, Lord Hunt, in his debate last week, when the noble Lord, Lord Judd, demonstrated how essential they are in monitoring themes such as gender equality, human rights and trafficking. I can confirm this from my own work with ASI and Christian Aid.
During a stay in South Sudan in February and an IPU visit to Kosovo two weeks ago-two post-conflict states at different stages of development-I realised, not for the first time, that international development can mean very different things. South Sudan is one of the poorest states on earth and we are engaged with its new Government, not always successfully, on designing better systems for delivering education, health and clean water. The World Bank trust fund, as in Afghanistan,
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In Kosovo, capacity building is much more formal and official. DfID has been a key actor in the building of confidence in institutions, and I was personally impressed by the advice it is giving to the Kosovo Assembly through Select Committees on issues such as finance, the constitution and the electoral system. In the main it is governance and the rule of law which receive UK funding. Kosovo has been a special concern of this country since NATO's intervention in 1999, yet DfID has decided to close its aid programme at the end of next year and this could prove very damaging. I must ask the Minister what provision there will be for the embassy-or perhaps the EU or one of the German agencies-to take over the programme.
Incidentally on the theme of governance, the CPA is holding an important conference here this week which is benefiting parliamentarians from all over the world. Kosovo is one of 16 bilateral programmes that DfID has decided to close down by 2016 so as to focus its bilateral spending on 27 priority countries. I am sure that the Minister will explain how they became priorities and whether it was the focus on the poorest rather than on post-conflict countries.
The question is: do we have enough confidence in DfID? Do its projects represent value for money? Will they make a real difference to the lives of the poor? Evidently the coalition is not satisfied with DfID's performance because it has commissioned a whole series of reforms and reports to make aid more effective and accountable. New Governments always do this to show up their predecessors and PR plays a role, but I know that the Secretary of State is personally committed to a strong humanitarian response, and his ministerial visits to Sudan and the Somali border testify to this. I am sure that he will encourage the excellence in DfID's programme.
I was pleased that the bilateral review has led to a new focus on the conflict states and an emphasis on tackling the two scourges of the poor: maternal mortality and malaria. In this context we should note on World Aids Day the real progress made against that appalling condition, and I also welcome the new all-party group of my noble friend Lord Crisp, which will deal with global health and the vital question of health workers. UCL and the Lancetare also continuing their valuable joint research on global health.
Last week saw the first four reports from a new watchdog, the Independent Commission for Aid Impact, which is to report to Parliament on whether the UK aid programme is making a difference and achieving value for money. This is a tall order judging from what I have read of the initial recommendations for Bangladesh and Zimbabwe. The commission will have to delve into many of our overseas programmes in detail and while it claims independence it will rely heavily on the
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Corruption is endemic in the poorest societies and has to be targeted within our aid programme. It can be eliminated. I have always been impressed by what the Crown Agents have done with the customs and port rehabilitation programme in Mozambique, which still has a big UK training component. However, the Public Accounts Committee report on 12 October found that DfID did not estimate levels of fraud and corruption. It said that its increased budget was bound to lead to higher spending on multilateral projects which would be easier to manage and reduce the need for monitoring and assessment. Perhaps the Minister could confirm whether this is true.
Aid effectiveness is the international buzz word and the Fourth High-Level Forum on Aid Effectiveness is taking place this week in Busan in Korea. This forum follows the Accra agenda for action designed to promote deeper partnerships in development which respect the diversity of aid and acknowledge the ownership of the country concerned. This is an important principle, well known to NGOs, that rich countries have no right to make decisions for poor countries, although in practice they do it all the time. I would like to think that DfID is pursuing the agenda, but in international development when the donor agencies interfere they always say that they are doing it in the name of good governance, accountability and transparency. In reality hypocrisy wins and conditionality remains a powerful weapon of aid.
I have mentioned India, which is having a fierce public/private argument about its services at the moment. I am glad the Government have kept it in the portfolio, although replaced by Ethiopia as the largest UK programme. The role of China deserves a debate all on its own. China has taken a prominent position in Africa, not least through its gift of the impressive new African Union headquarters in Addis Ababa which will open with great ceremony next month. It is a significant investor in east Africa. Earlier suspicions that Chinese workers were replacing African ones were unfounded and China has a good reputation for major infrastructural schemes, such as roadbuilding and agricultural development. DfID has already looked at ways of working more closely with China on rural projects; I trust it will do so again. Investment in agriculture is vital, especially seen in the context of the effects of climate change-now being discussed in Durban-which hit the rural poor most of all. Is DfID doing enough to help these small producers, men and women, with agricultural extension schemes and to encourage the private sector to help finance transport and rural roads and so improve trade and food distribution?
There have been growing criticisms of land grabbing in South Sudan, Uganda and elsewhere by farms and forestry schemes, some of which are based in the UK. Multinationals are adept at evading codes of conduct and corporate responsibility although there are exceptions.
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For many years I have admired the effectiveness of the International Development Association, which has done a lot for small farmers. However, I understand that even IDA is in the business of promoting private enterprise well out of reach of these farmers and perhaps at their expense. One of its loans to Mali, for example, covers the salaries of a Malian investment promotion agency. Will the Minister say whether the coalition should be supporting this kind of profit-led promotion?
In conclusion, I take noble Lords back to my original statement about public opinion. The Government have a mandate to use a very generous budget not only to bring relief from suffering but to enable the poorest farmers and many other communities to achieve a sustainable livelihood and thereby bring down the numbers suffering from hunger and the price of food as a matter of urgency. Will the Minister confirm that the Government are fulfilling this mandate? I beg to move.
1.59 pm
Lord Judd: My Lords, I am sure that the whole House will applaud the noble Earl, Lord Sandwich, for having secured the debate and for having opened it so effectively. His commitment on these issues is steadfast. Like him, I greatly look forward to the maiden speech of the noble Lord, Lord Singh of Wimbledon, with all his background and experience.
I am, naturally, glad that the Government remain firm in their objective of securing 0.7 per cent of gross national income for the aid programme by 2013. However, apart from its diminishing value in real terms in the context of global financial realities, it is important to know what exactly is the Government's definition of aid. It seems it is being repeatedly stretched to make up for cuts at the Foreign and Commonwealth Office and elsewhere.
It is interesting that the noble Baroness, Lady Northover, is to reply to the debate. She has a long-standing reputation, established in opposition, not only for advocating 0.7 per cent but of constantly underlining the importance of the quality of the aid and development provided within that objective and, very significantly, of supporting the central related policies in the sphere of international rights, finance and trade.
I pay tribute to the many NGOs, whose work on international aid and development has been a bedrock of increased political commitment by all the principal political parties. Their advocacy is of a high standard, based as it is on real front-line experience. In preparing for this debate, I have, yet again, found invaluable the insight, analyses and challenges provided by Oxfam, of which I am glad to have been a previous director, Saferworld, of which I am a trustee, and the World Development Movement.
The debate is well timed. The High-Level Forum on Aid, effectively, is reaching its conclusions in Busan, South Korea, as we deliberate here today. Can we be
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DfID has announced its intention to reduce the amount of UK aid spent on budget support around the world by 43 per cent. Can the noble Baroness tell us more of the real rationale for this? While aid given directly to the budgets of developing countries may, of course, sometimes cause difficulties in measuring instant results, it can surely be an excellent means of achieving sustained positive outcomes. It allows developing countries to make long-term investment in the core services, such as the health and education systems. Is there not a danger that, in overstressing aid for specific targeted projects compared with demands for measurable short-term outcomes, the sustainable development process will be distorted and undermined? Is DfID, in its plans, and with its preoccupation-some might say obsession-with targets, getting that balance right? How will the indispensable long-term funding to establish essential supporting systems be ensured? Frequently the real sustained effect of aid can be measured only in the long term. That is certainly my experience of years of involvement.
Seven million people are already facing acute food shortages in Niger, Chad, Mali, Mauritania, Nigeria and Burkina Faso. This indicates that next year there will be a massive problem of food availability and the danger of widespread famine will become acute. The danger is all the greater because people have not yet had the opportunity to rebuild their assets and increase their resilience after the severe crisis of 2009-10. If in a so-called normal year 300,000 children die in the region from malnutrition-related causes, any small addition, whatever form it may take, can push these catastrophic figures disastrously higher still.
Greatly to their credit, the Governments of Niger and Burkina Faso have already signalled they will need assistance. In the light of these indications and clear warnings, and taking into account DfID's commitments made in response to the challenging Humanitarian Emergency Response Review of the noble Lord, Lord Ashdown, to strengthen anticipation and early action in disasters and to build resilience to disasters, what exactly are the Government doing convincingly to apply these commitments in the grim realities once more accumulating in the Sahel?
Meanwhile, climate change poses a grave threat to food production and to the livelihoods of the poorest communities around the world, most especially of women, who rely on being able to grow their own food to survive. Changing rainfall patterns, longer and more severe droughts, floods and rising temperatures all present acute challenges to farmers and make it difficult for them to know when best to sow, cultivate and harvest their crops. This will inevitably eventually lead to vast movements of people, aggravating the pressures of migration and provoking instability.
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