Thursday 27 October 2011
[Mr Clive Betts in the Chair]
NHS Care of Older People
Motion made, and Question proposed, That the sitting be now adjourned.—(Paul Burstow.)
It is a pleasure to serve under your chairmanship this afternoon, Mr Betts. I thank the Backbench Business Committee for allowing us to have the debate this afternoon, and I am grateful to colleagues on both sides of the divide for supporting it. I look forward to hearing the views of other people who have a great interest in the subject.
We are here because of troubling reports about the care of older people in the NHS. I was prompted to confine our debate to the NHS by the report from the Care Quality Commission two weeks ago, which studied 100 NHS hospitals. The report was by no means an isolated study; it came on the heels of the ombudsman’s report in February and Age UK’s “Care in Crisis” report in May.
That we have a worrying problem is beyond doubt, but I hope to bring a balanced view to the debate. It is important to note that even when reports give cause for serious concern, there are significantly more examples of good and acceptable care than there are of bad. Indeed, the ombudsman’s report stated that the overwhelming majority of patients say they receive good care. I will return to the balanced view that I promised, but first I will outline the concerns raised by the latest findings of the CQC.
The Secretary of State commissioned the CQC to undertake a series of unannounced inspections in response to the ombudsman’s report. The inspections focused on outcomes, interviews with patients and staff, and observation on the wards. Two outcomes were measured: respecting and involving people who use services, which includes care, dignity and respect for privacy, and meeting nutritional needs. Forty-five of the 100 hospitals met both standards in full; 35 met both standards but needed some improvement, and 20 were not even delivering care that met minimum legal standards. Of those 20, Sandwell General hospital and the Alexandra hospital in Worcestershire—both quite near my own constituency —were found to be putting patients at unacceptable risk of harm.
If we look in more detail, we see that 60 of the hospitals were found to be meeting a good standard in respecting the dignity and privacy of patients on both the wards observed by the CQC. Staff behaved in a way that respected patients; they were positive, sensitive and respectful; they involved patients in decision making and explained treatment options properly. Where there were problems on this measure in the other 40 hospitals surveyed, not one of the hospitals was found to be failing on both the wards observed. It is noteworthy that the report found a large degree of variation in practice, and I will return to what I think that says about management and leadership later.
On the nutrition outcome measure, 17 hospitals were failing to reach an acceptable standard. Patients in need of assistance at mealtimes were not getting help; food was placed out of reach; there was no monitoring of whether patients had eaten their meal and there were constant interruptions during mealtimes. For example, a clinical round would suddenly start during lunchtime. Age UK’s report, “Still Hungry to Be Heard”, found that 157,000 people left hospital malnourished in 2008, and that the figure had increased to 185,000 in 2009. Astonishingly, 239 patients died from malnutrition in 2007.
New research published last month found that across the NHS, 9 million meals are returned uneaten per year at a cost of £22 million. One of the problems is whether we can serve three appetising meals of decent nutritional value for less than £5 per patient, which is what my own local hospital budgets for. I would say that we cannot.
As I see it from the two reports, when the scale of the problem is considered across the entire older population who are being cared for in our hospitals, it is not as great as is often reported by the media in the immediate aftermath of yet another report. However, for the older patient on the end of the worst care, it amounts to cruelty and neglect by staff.
My hon. Friend makes a very good case. On the key findings of the CQC report, which the media seem to report as a failure of nursing when the bulk of them are really issues of care, will she also cover the issue of the resources that appear to be going into hospital wards, particularly with the increasing acuity and turnaround of patients, and nursing and care staff to patient ratios, which appear to be on the edge in many cases?
I thank my hon. Friend for making a very good point. I will return to the resourcing issue. I do not have statistics on the staff to patient ratio, but it is noticeable that it is much better in paediatric wards than in wards with large numbers of older people. Perhaps we can learn from that.
I was talking about cruelty and neglect. Staff are paid to care in institutions that are for the most part monopoly public services; the patient has no choice but to be there. In Age UK’s 2010 research, 21% of patients said they were not always treated with dignity and respect, and there has been no improvement in that figure since 2002. The figure is fairly consistent with the CQC findings and it seems to be consistent with other reports. It leads me to think that the problem we must address is twofold: first, the overall figure of one in five being essentially ignored—or worse—in our hospitals is simply too high, and secondly—the worst aspect—nothing ever changes that figure. Despite all the reports and information, nothing actually changes that figure.
Care is failing one in five of our older patients two or three times a year. The new research confirms that failure, but no effective action is taken to remedy it or to reduce the problem. I hope that as a result of our collective ongoing efforts, we will finally make a significant impact on the problem. It is likely that one of the reasons for the inaction that has persisted for a decade or more has its roots in a wrong or partial diagnosis of the causes of the problem, so I will turn to the various causes that have been advanced by research and informed commentators on this state of affairs.
The causes that I have read about can be grouped under the following headings: leadership, management, resourcing, training and what I loosely call societal. The leadership of individual hospitals such as Stafford—to take the worst example—sets out daily through a series of explicit and subliminal messaging what it is important for staff to deliver in that institution. At most, the focus from the top will resonate further down the line in only one or two areas. Staff know, either consciously or unconsciously, that if they deliver on one or two variables, they will not be seriously picked up for partial or non-delivery elsewhere. That is the same in any large organisation. Often, the overriding concern at the top in NHS hospitals is about meeting financial targets, just as it was in Stafford. In other cases, rigidly applied clinical outcomes might bear little relation to how a patient is treated by staff before and after their care or surgery.
Leadership does not come only from the chief executive and key board members. I served on the board of an NHS trust that was answerable, in a mechanistic, command-and-control way, to the Department of Health, which in turn was accountable to the Secretary of State—I am going back 10 or 12 years. Political pressures on a Secretary of State are principally financial, but they also concern global outcomes in politically sensitive areas such as cancer. The day-to-day treatment of patients is often delegated to a regulatory quango, but irrespective of the party in power, the Secretary of State will survive the occasional embarrassment and discomfort caused by yet another report. That explains the extraordinary situation whereby the care problems at the James Paget University hospital in East Anglia were serious enough to warrant a warning notice from the Care Quality Commission, but nurse training at the same hospital was well rated by the Nursing and Midwifery Council.
Although overall management and culture is set by the board, the main divide between good and bad management depends on the effective deployment of resources, the motivation and discipline of staff, and the systems for gathering customer—or patient—intelligence. The CQC noted that in some wards, levels of under-resourcing made poor care more likely—the point raised by my hon. Friend the Member for St Ives (Andrew George). Patients commented to the CQC about how hard pressed the nurses seemed, and that was confirmed by comments about the report by nurses writing on blogs. Even allowing for a certain amount of, “They would say that wouldn’t they?”, some of the remarks seemed heartfelt and genuine.
Interestingly, however, none of the hospitals where care was found to be poor was found wanting in all the wards inspected. Unacceptable levels of care were seen on well-resourced wards, and excellent care was found on wards that were understaffed. That indicates that the issue has more to do with ward leadership and the personalities and values of nurses in leadership roles than with the overall budget at the disposal of hospitals where problems were encountered.
I am not sure that I draw the same conclusion as my hon. Friend. She suggests that resourcing is not particularly relevant when considering the quality of care achieved, but surely she accepts that the situation is far better, and high levels of care more likely, when resources are adequate.
I agree that care is more likely to be good when resources are adequate, but poor care has been observed on wards that the CQC regarded as well resourced. I do not draw a neat and fast conclusion, and having worked in business for many years I accept that resourcing is important. It is difficult to generalise from the available research, but I take my hon. Friend’s point.
On nurse training, the CQC found that half of hospitals were ailing in the areas of privacy and dignity; staff had little training in matters of privacy, dignity, rehabilitation and dementia. Training, and the lack thereof, is a symptom of the growing and unregulated use of health care assistants. In a report out today, the Royal College of Nursing states that in some parts of the country, 40% of staff on a ward are health care assistants. I will return to that point.
Another important issue is the general training of nurses. Consensus seems to suggest that although Project 2000 brought benefits to nursing status and career paths, the effect on care has been less positive. Earlier this year, Camilla Cavendish, a journalist from The Times, undertook extensive research across the country. Her observations suggest that Project 2000, which moved training from hospitals to universities and gave it degree status, has led to nurses spending too little time on wards during their training, and they are under-prepared to deal with patients when they graduate. Project 2000 has also led to gaps on wards, which have been filled by health care assistants. Such assistants are supposed to be supervised by nurses, but although I have no evidence either way, I wonder whether nurses have the training for such supervision.
Patients often think that health care assistants are nurses, and it is not always easy to distinguish the two posts. Health care assistants, however, have almost no training and perform non-medical tasks such as providing help with feeding and washing. I am sure there is a degree of mission creep into areas that require some form of training, and I shall return to that point. Perhaps it is no wonder that many nurses feel that certain aspects of caring are menial work.
My hon. Friend suggests that nurses see caring as menial, but that is not an observation I would make. I had the opportunity to shadow nurses in four wards, and they told me that they wished they had more time to perform a caring role in addition to their clinical duties. Such a role would fulfil the observational function that nurses are trained to perform in order to continually assess a patient and review their diagnosis. That nurses believe themselves to be above a caring function is not a conclusion that I would draw, and I believe that it besmirches the professional standing and pride felt by a lot of nurses.
My hon. Friend makes some good points. Camilla Cavendish visited hospitals across the country as part of her research and spoke to many patients and nurses, and the view I have mentioned was expressed not only by patients but by nurses. I am sure that such cases are in a minority, and I certainly do not intend to besmirch the good reputation of the majority of nurses. However, the research leads me to believe that a minority of nurses either do not have time for care or feel that although care is not beneath them, it should be carried out by staff at a different level. That is a legitimate view and has been expressed in a variety of nursing journals and other forms of media by retired nurses who have visited hospitals. My hon. Friend should not dismiss that element of concern, and I emphatically do not wish to besmirch the reputation of our many good nurses. However, when we read in the CQC report about the problems engendered by the very poor care that some patients receive, we realise that we cannot afford to dismiss any of the conclusions reached by people who have done a lot of research.
I want to move on to some societal observations. The ever-increasing use of scientific and technological advances brings many benefits, but it also creates a work environment that requires nurses to concentrate on aspects of treatment and care that isolate them from the patients whom they are serving. The workplace in general outside hospitals is becoming more mobile. People connect with one another far more via devices of various sorts. That presents a risk to the caring professions that needs managing.
Then there is the issue of the pool of talent from which nurses and other caregivers are drawn. This summer saw an explosion of violence, avarice and selfishness on our streets on a major scale. Although work is ongoing to identify the cause of that phenomenon, it is clear to many of us that the fault lines in our social fabric are every bit as wide and deep as suggested by the research undertaken by my right hon. Friend the Secretary of State for Work and Pensions, before he came into government. These incidents affect all walks of life. Much more could be said on that point, but I do not intend to elaborate on it now. For the purposes of this debate, the implication is that nurses are as much a reflection of modern Britain, with its drawbacks—a society in which a significant minority seem to be more aware of their rights than their responsibilities—as well as its strengths.
Likewise, patients and their families reflect society. Melanie Reid, a columnist for The Times, spent a year in a spinal injuries unit following a tragic accident. She wrote an excellent piece on the nursing debate three weeks ago. She said:
“If you want to change nursing, you have to change society. You also have to change the patients. Today’s sick are…not deferential sufferers in silence. They and their relatives can be aggressive and unreasonable.
Everyone’s a professional complainer. During my spell in hospital, I saw some patients whom, had I been forced to cope with their constant demands, I would have smothered at dawn. Instead, the staff treated these people with civility and good humour.”
I shall turn now to some conclusions and recommendations. I shall conclude with what I think needs to change and I hope that the list of areas to which I refer will provide a platform for further consideration by the Government. I note that the Government are already making positive changes in some of the areas, and that is welcome. My priorities for change would centre on the importance of food and nutrition in hospitals and the standards in that respect; the accountability of boards and chief executives for the care of patients; resource allocation; the inspection regime; hospital complaints procedures; and nurse and health care assistant training.
I welcome that intervention because whenever one is preparing for a debate such as this, one is conscious of how much more there is to say than one has time for. I was not intending to draw too many conclusions on what needs to change in society. I was concentrating on what needs to change in the domain that we are discussing, but perhaps the hon. Lady would care to call for a debate on the topic to which she has referred. I am sure that we could fill an afternoon with such a discussion and I should be delighted to take part.
One matter that needs to be thought about carefully in this debate if not elsewhere is, of course, the integration of the NHS and social care, because that will help the process along and deal with many of the issues to which my hon. Friend is referring.
I thank my hon. Friend. That is a very good point. The integration of health and social care should, with the weight of joint commissioning behind it, make quite a difference. My speech has concentrated on care in hospitals, but I hope that other hon. Members will bring out issues to do with care at home and other aspects of what the NHS delivers.
I shall go through my list of recommendations briefly. On nutrition, the Age UK report, “Still Hungry to Be Heard”, advocated that ward staff needed to be “food-aware”. Training should include nutrition and the importance of assistance with meals when needed. I agree with these recommendations. Older people should be assessed for signs of malnourishment on admission, during their stay and on discharge. Hospitals should introduce protected mealtimes. Where they are using a red tray system, which involves a red tray being given to patients who require assistance with eating, staff should be trained in how to use it. It sounds as though that system works well where it is used properly.
I thank the hon. Lady for her generosity in giving way to me again. Does she question, as I do, the red tray system, in that if nurses and nursing staff understand the needs of a person, surely they should understand what their nutritional assistance needs are without the use of a red tray? Surely they should know patients well enough already. Is that not a question that we should ask?
I thank the hon. Lady for her excellent point. In an ideal world, I would strongly agree with her. I agree that what she has suggested is to be desired. The trouble with relying on that is that the throughput of patients through wards these days is quite fast, the rostering system for nurses is very complicated and the continuity of care is certainly not as good as it used to be. Many nurses work intensively for a week and then have a substantial amount of time not working. Therefore the personal relationship, which is so desirable, has been compromised to the extent that we can no longer rely on it to ensure that patients’ nutritional needs are met. That is why I believe that the red tray system is useful. However, I am very concerned that people could easily think, “Oh well, that sorts the problem out,” and not feel that they need to relate to the patient in the way that the hon. Lady suggests.
I come now to accountability. I realise that this is not something that the Government can mandate, but chief executives should come on to the wards regularly—every day that they are in work. Nurses used to be accountable to a matron, who would turn up unannounced to check on standards. We must replicate that discipline again, and I recommend starting at the top.
Managers need to ensure that budgets are used wisely to support front-line staff and that front-line staff are not distracted by other, non-patient-care “priorities”. I looked at nurse blogs when I was preparing my speech and I sympathised with one nurse who said that nurses are
“at the beck and call of so many departments who wish to give work away and have no qualms in ‘getting the nurses to do it’. Loan stores, training, HR, to mention a few who seem to have forgotten that their role is to support us—not the other way around.”
I have sympathy with busy nurses who are pulled in all directions.
I am grateful to my hon. Friend for giving way to me a fourth time, which shows how patient she is with me. Quite apart from falling into the trap of conflating care with nursing in some of her remarks—she did make the point about needing to ensure that there is a clear distinction between care assistants and nurses—does she not also agree that in terms of the management on wards, a lot of nursing time is taken away from the patient interface as a result of the enormous amount of bureaucracy and paperwork required and the pressure that many nurses come under from bed managers, who appear to overrule them when it comes to determining when a patient should be discharged or admitted to a ward?
I thank my hon. Friend for his observation, and I certainly agreed with the first point he made. I shall conclude in a minute as I am aware that many Members wish to speak.
The CQC should be resourced to ensure that its inspections include weekend visits. All the observations it makes in its recently published report were based on visits it paid during the week—for cost reasons, I imagine—but I was delighted to hear the Secretary of State announce yesterday that there will be more inspections. I hope, however, that the Minister will discuss with the CQC the possibility of visits being paid at weekends, when—I hear—care can sometimes deteriorate rapidly.
Some complaints are very serious, and I am not commenting on serious medical negligence, but with many complaints the system comes over as a sledgehammer to crack a nut. A patient or family member should be able to make an informal, non-legalistic and reasonable complaint and receive a sensitive hearing from a senior member of staff, rather than be instantly given a form that starts a three-week process of churning and often ends in Members’ surgeries. I ask the Minister to discuss with the Justice Department how we enable that but avoid opening the hospital to legal challenge, which is one of the motivators to the heavy-handed system we have at present.
We must be able to distinguish between the training needs of nurses and health care assistants.
I thank my hon. Friend for that intervention, and I am attracted to that good idea. Somebody must be in charge of the ward—a nurse manager or a matron. Although that happens in the best wards, it is not universal.
We must look at the training of health care assistants, who increasingly perform sensitive, caring roles; the system cannot be left as informal as it is at present. There must be minimum standards and training. We know that there is pressure to register health care assistants. I am not sure that that is necessary, but training and minimum standards certainly are.
I challenge where Project 2000 has got us. Nurse training could remain at degree level but follow a more apprenticeship-based model. I ask the Minister to meet the Nursing and Midwifery Council to discuss how the nursing degree can learn from the apprenticeship model so that far more time is spent on the ward, alongside the academic study that has brought such benefits.
There is much more to be said, and I look forward to hearing from other hon. Members and learning from their contributions. I thank the many organisations that have been in touch with me and helped with my research since I secured the debate last week.
It is a pleasure to speak in the debate when you, Mr Betts, are in the Chair.
The full title of our debate is “NHS Care of Older People”, and the fact that that distinction is made shows that there is an issue in the care of older people by the NHS that needs to be discussed. It is right, therefore, that we are debating this matter today and I congratulate the hon. Member for Stourbridge (Margot James) on securing this debate and on the way in which she opened it.
A number of reports made to Parliament this year on the failings of NHS care of older people have shocked us. The health service ombudsman, Ann Abraham, reported in February on a
“picture of NHS provision that is failing to respond to the needs of older people with care and compassion, and to provide even the most basic standards of care”.
Her report told the stories of 10 people over 65—partners, parents and grandparents: individuals who put up with difficult circumstances and did not like to make a fuss, compared with those who, as we have heard, were difficult—who wanted to be cared for properly and, at the end of their lives, to die peacefully and with dignity. Ann Abraham tells us that what the people involved have in common is their experience of unnecessary pain, indignity and distress while in the care of the NHS.
The second of the 10 stories is that of Mr D, and it particularly focuses on the last five days of his life. He was admitted four weeks earlier with a suspected heart attack but after tests was diagnosed with advanced stomach cancer. He was to be discharged from hospital on the Tuesday after the August bank holiday weekend, but it was brought forward to the Saturday. The summary of the story in the report is harrowing. The discharge of, we must remember, a man with only a few days to live was a shambles. The report goes on:
“On the day of discharge…the family arrived to find Mr D in a distressed condition behind drawn curtains in a chair. He had been waiting for several hours to go home. He was in pain, desperate to go to the toilet and unable to ask for help because he was so dehydrated he could not speak properly or swallow. His daughter told us that ‘his tongue was like a piece of dried leather’. The emergency button had been placed beyond his reach. His drip had been removed and the bag of fluid had fallen and had leaked all over the floor making his feet wet. When the family asked for help to put Mr D on the commode he had ‘squealed…’ with pain. An ambulance booked to take him home in the morning had not arrived and at 2.30 pm the family decided to take him home in their car. This was achieved with great difficulty and discomfort for Mr D.
On arriving home, his family found that Mr D had not been given enough painkillers for the bank holiday weekend. He had been given two bottles of Oramorph (morphine in an oral solution), insufficient for three days, and not suitable as by this time he was unable to swallow. Consequently, the family spent much of the weekend driving round trying to get prescription forms signed, and permission for District Nurses to administer morphine in injectable form. Mr D died, three days after he was discharged, on the following Tuesday. His daughter described her extreme distress and the stress of trying to get his medication, fearing that he might die before she returned home. She also lost time she had hoped to spend with him over those last few days.”
The summary of this case sounds terrible, but the detail was much worse. The family were my constituents and I supported the family’s complaint after meeting Mr D’s daughter. Every aspect of this case showed the NHS in a very negative light.
Let me give a summary of the detail in Mr D’s case, as reported to the ombudsman. Mr D was not helped to use a commode and fainted, soiling himself in the process. He was not properly cleaned and his clothes were not changed until the family requested that the following day. The ward was dirty, including a squashed insect on the wall throughout his stay and nail clippings under the bed. He was left without access to drinking water or a clean glass. His pain was not controlled and medication was delayed, sometimes by up to one and a half hours. Pressure sores were allowed to develop. No check was made on his nutrition. His medical condition—the fact that his illness was terminal and that he had only a few days left—was never properly explained to his family. He was told of his diagnosis on an open ward, overheard by other patients.
I spoke about this case in a debate about the NHS Redress Bill, and I agree with the comments that the hon. Member for Stourbridge made about accountability. Where was the accountability in this hospital? Where was the ward manager or matron figure who was letting these things happen?
At this point, Mr D’s daughter, a constituent, came to me for help. She desperately needed an answer and an explanation of what had happened. As her MP, I felt the hospital needed to admit its errors and take measures to ensure that what happened to that patient did not happen to anyone else. Regrettably, in the months that followed, the hospital seemed unable to do that. In fact, the dreadful failures in care and communication were made worse by the inadequate way the hospital dealt with my constituent’s complaints, as I reported to the House in that earlier debate.
After raising her complaint with the hospital, my constituent found that responses from it were not sent in keeping with agreed time scales and often took three or four weeks longer than it had promised. Copies of responses from the hospital were never sent to me, and I had to chase every single one of those responses, which were often inadequate. That was the worst thing for this bereaved family, because the delayed answers and prevarication from those investigating the complaints left the family feeling more angry and upset. Their anger was originally due to what they perceived as delays in diagnosing Mr D’s terminal condition and the poor treatment and care he received, but the whole thing became worse because of the way the case was handled.
The complaints the ombudsman’s report details are very serious, and I am talking about just one. In making their complaint, the family know that nothing can bring back their loved one—their father—or change the way he was treated, and families often tell us that. However, the family desperately want explanations and an apology, and they desperately want to ensure that no other parent is treated the same way.
The hon. Lady is making an incredibly moving speech. I pay great homage to the work Ann Abraham has done in her role as ombudsman, and yet another fantastic report came out last week about the complaints procedure. Does the hon. Lady agree with the recommendation in that report that there should be far greater partnership working with organisations such as the Care Quality Commission? Does she agree that the Government could take steps in response to the findings of the consultation they have just held on the information revolution? Such measures would really help improve the complaints procedure, which would drive up standards of care.
Yes, indeed. We discussed those issues in relation to the NHS Redress Bill. The difficulty we have with the most extreme cases, as I am describing in relation to my constituent, is that the medical establishment seems to close up when facing such complaints, and people become fearful that they will be sued and have problems in their careers. We must remove that way of handling such awful cases, because it is just not acceptable.
Like every MP, I understand that the Government cannot manage every consultant and every ward to make sure such things do not happen. However, they do happen, and there are many more cases than the 10 the ombudsman reports on. We must bring about a change of culture to allow for an acknowledgement of the fact that there must be better redress than there was in this case when a whole system of care and treatment fails a patient and his family, and when standards of professional practice and communication fall. The MP and the family should not have to battle the complaints system and eventually take their case to the ombudsman because only the ombudsman can ever make a hospital do what it should have done in the first place.
The family were looking for an acknowledgement, an explanation and an apology, and they wanted to make sure that these things did not happen again. It is very reasonable that they should expect that.
The hon. Lady is making an incredibly important point about how complaints are handled in the NHS. In highly effective organisations, complaints are considered to be gold dust, because they are part of how those organisations drive up standards and improve services. That benefits not only the patients, but staff. It is so demotivating if staff working on poorly managed wards, or in the NHS more generally, raise complaints, even through protected disclosures, and nothing happens. That can cause them stress and great personal harm.
The hon. Lady is making a strong case. On the point about whistleblowing, or protected disclosure, her own research may have shown that when a nurse, for example, suggests to senior management that there is a resource problem on a ward, that does not necessarily enhance their likelihood of improving their job prospects in the hospital. Often, they are told, “Other members of staff seem to manage, so why don’t you?” Does the hon. Lady agree that we need to look at how whistleblowing can be done safely?
It is clear that what I said about culture must apply right through to things such as whistleblowing. It is a sad aspect of this case that none of the people involved with Mr D’s care or with dealing with the complaint could even rescue the situation by handling the complaint reasonably.
I understand, and we must be clear, that this case represents the NHS at its worst, but it did happen, and it happened to my constituent. I have never had a case as bad as this one again, but I have had others that have given me cause for concern, and I am currently pursuing cases with similarly bad aspects on behalf of constituents. Sometimes, however, there are cases where everything goes wrong and all the problems I have mentioned come together.
MPs’ interventions and the intervention of the ombudsman can remedy the injustice of such inadequate treatment to some extent, but we must accept that it is not possible even for such interventions, much though our constituents are grateful for them, to overcome the distress and anguish experienced by families such as my constituents. However, a swift apology would have helped, and we must have a system whereby an apology can be made swiftly, because that never happens.
The ombudsman talked about the need to listen to older people and to take account of feedback from families. One of my conclusions from having looked at this case is that it took many months—in fact, years—to get to the point where the family were anything like happy with the response to their complaint, and that made things worse.
I felt it was important to outline a case I had personal experience of, and there has not been time to touch on much else, but there are many things that could improve this situation. In the briefing for the debate, I was heartened to see a note from the Women’s Royal Voluntary Service describing ward support services it is setting up for older people, which is a wonderful idea. It wants to improve the experience of older people by using trained volunteers to support them and their families and carers. That would include training in dementia, which could be important.
Hospital support for carers is also important. The Princess Royal Trust for Carers has a carers centre in Salford, which the Minister knows, because he has met some of its staff. The centre has developed strong relationships with primary and secondary health care and works closely with Salford Royal hospital, which does excellent work—it is not the hospital I was talking about earlier; that was a different hospital. The centre supports carers in the hospital and on important issues around discharge. How could the discharge I described have happened if people had been there—even volunteers and people from a carers centre—to help the family? Such initiatives can help.
Developing awareness of family carers on hospital wards and giving them support might help to head off, or somehow deal with, dreadful situations such as the one I have described. NHS care is important, but it is important that we understand that it does not end when a person leaves hospital, particularly if they are terminal patients going home to die.
I hope the debate contributes to the improvement of NHS care for older people. As a Member of Parliament, I would never want to see another case like the one I have described.
It is a pleasure to serve under your chairmanship, Mr Betts. I congratulate my hon. Friend the Member for Stourbridge (Margot James) on securing the debate through the Backbench Business Committee, and all hon. Members who supported the call for it—as I did.
I do not pretend to be a health care professional, even though I use the title “Dr”. Nor do I profess expertise in that area. However, the care given to those older people who need it—I tend to use the word “elderly”, although it may not be politically correct—is important. Usually, the start and end of life is when we use NHS care the most, and those people should be given the best care possible. We should make sure failures are dealt with, and we should speak up about them in Parliament.
Given the time constraints, I had thought of spending a little time on talking about the terminally ill. Hon. Members may know that I have introduced a ten-minute rule Bill on the provision of hydration and nutrition. We have also had Westminster Hall debates about palliative care in eastern England, and I recognise the valuable work that is done. However, it is right to focus on the Care Quality Commission report and individual hospitals, so that our constituents know we are speaking up for them, and so that their voice is heard in Parliament.
My hon. Friend the Member for Stourbridge went into great detail about the CQC report, and the hon. Member for Worsley and Eccles South (Barbara Keeley) went into detail on a particular case. The view of representatives of the Royal College of Nursing, given in informal discussions, about evidence given or sentiments expressed in submissions to the Francis inquiry, was telling. There was concern about leadership and about how people would be treated if they stood up and spoke up for patients—that they would be ignored, or, worse, demoted. I am sure that that shocked the nursing profession and other people, and I recognise that attempts are being made to deal with that, so I do not mean to be condemnatory.
My constituency has the 15th highest proportion of pensioners. Some 55% of my constituents are over 55, so the issue we are discussing is important there. The constituency also covers two primary care trusts—NHS Suffolk, and Great Yarmouth and Waveney—and we have three hospitals that provide care. They are the Norfolk and Norwich university hospital, Ipswich hospital and James Paget university hospital. I am afraid that two of those were on the list of failing hospitals and, understandably, local residents were very upset. That is reflected in the number of complaints made to me, or copied to me, about people’s experiences when they are trying to get care.
As to Ipswich, after the first failure, I and my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter) met the chairman and director of nursing. I was impressed straight away that the director of nursing recognised absolutely that there had been failings. That recognition and acceptance of failings was important to me. The suggestion was made at the time that not all the staff accepted, initially, that there were failings, and that the feedback was met with an element of rejection. However, every member of staff quickly recognised that things had to change.
An action plan of changes and improvements to local ward leadership was set out, and fresh training was provided. A high focus was put on that, including additional support for patients with dementia. The hospital was inspected on a second occasion and, although the report has not yet been formally issued, I understand that it will pass—it should be congratulated on that—that a marked improvement was noted and that patient satisfaction was much higher.
It is worth distinguishing between acute and community hospitals. That would inform the debate, because, obviously, chronic and non-chronic conditions are different. It would be helpful to know which hospitals are which, and whether that will help us to think about the subject.
Ipswich hospital is a district general hospital, if that helps my hon. Friend. It provides acute care, and is not just focused on community care. I want to say thank you and well done to the director of nursing and all the medical teams at the hospital for the changes they have made.
In contrast, James Paget hospital, in the constituency of my hon. Friend the Member for Great Yarmouth (Brandon Lewis), has failed a second inspection. The second report showed improvements, but not consistent improvements. There were still minor concerns in several areas, and continued moderate concerns on meeting nutritional needs and the management of medicines. The second report is complimentary about staff and training, and, as my hon. Friend the Member for Stourbridge has already mentioned, the hospital was cited in a Nursing and Midwifery Council report as having good training levels. To reinforce that point, the CQC suggested that patients’ needs were generally met. At times it was possible that not all the staff were available or deployed in the most effective way, but generally patients had the staffing appropriate to their needs. The third inspection has taken place. Its outcome is not yet formally known, and the hospital has not received the draft report, but I have not heard positive vibes so far.
As to my interaction with the leadership, I must say at the outset that I recognise that it was limited. My hon. Friends the Members for Waveney (Peter Aldous) and for Great Yarmouth have taken a much greater role, because a relatively small number of patients from my constituency go to the hospital in question. After the first inspection, however, I was assured that the failures were just a blip, and that things were already under way. Doubt was cast on the quality of the inspection carried out by the CQC—that was said to me by the chairman of the hospital trust. I did not accept that, because those CQC inspections are intended to be a snapshot and to take a view. Frankly, if one patient experiences bad care, that is an automatic failure. I think that hon. Members would recognise that.
I was reassured, however, by the expectation of changes, which were under way; but, as I have mentioned, the second inspection continued to find failings in dealings with older patients. I did not meet the hospital manager and chairman after the inspection, but my colleagues did and I was not reassured by the report of that meeting. Yet again it seemed that doubt was being cast on the validity of the CQC inspection by the chairman of the trust—though not, I understand, by the chief executive.
We three MPs have together agreed a course of action to press the hospital on its improvements for our constituents, and it has responded. As I said, a third inspection has been held, and I am highly concerned that a third failure will be reported. Monitor has now issued a red governance rating, which I believe is automatic, but I understand that it has also had conversations with the leadership. I have received copies of constituents’ complaints, and seen a whistleblowing letter from GPs from the consortium Health East. The letter says:
“As a group of concerned GPs we have been forced to pursue this whistle blowing option, because we are concerned that our new GP consortium ‘Health East’ may fail to be successful due to the failings of our main, acute provider the James Paget University Hospitals NHS Foundation Trust.
Health East will be depending on the Trust to provide the acute care for most of our patients and we have lost confidence in the ability of its leadership to correct its current failings. Please act quickly before we have yet another Mid Staffs on our hands.”
“We apologise once again for having to take this whistle blowing option, but we need you to put pressure on appropriate organisations to put the issues right before our patients suffer.”
I do not suggest that someone going into the hospital will automatically suffer poor care, but that is the reaction of GPs who are expected to work with patients to ensure that they receive the best care.
In the circumstances, it is my role to press the leadership of the James Paget hospital on constituents’ behalf. In particular, the chairman of the hospital trust should consider his position. I appreciate that the financial risk at the hospital is low, and that that may reflect good financial governance, but patient care is key. The chairman has provided useful leadership, but—after two failed care inspections and with the possibility of a third—it is time for him to step aside and allow new leadership to come forward.
I will apologise to the chairman of the trust, because although I sent him a communication about what I would say in this debate, I could not speak to him personally. I should also say that I do not make my suggestion on behalf of my hon. Friends the Members for Waveney—who is in his place—and for Great Yarmouth. I do not make such a call lightly, but there is concern that patients may be reluctant to go to that hospital. Perhaps that is not a widely-experienced feeling, but often people worry about going to a particular hospital because of the perception of concern. We cannot afford that, and must not stand quietly by without expressing a view.
I have spoken for 10 minutes and understand that others want to speak. There are other issues, such as community care and confidence in that. My hon. Friend the Member for Central Suffolk and North Ipswich and others, including myself, have pressed the case about ambulance services and response times. Some of our constituents live more than an hour from the nearest hospital, so concerns about failure to respond within the eight-minute target are appropriate. I am meeting Ministers another time to discuss that matter.
I do not make the request that I made about the James Paget hospital in Parliament lightly, but I believe that it is necessary for the safety, well-being and protection of patients in Suffolk Coastal.
I congratulate the hon. Member for Stourbridge (Margot James) on securing this debate and on her thoughtful contribution. Other hon. Members have also shown great insight in their representations.
Like others, I was sickened by the reports that we received from the Care Quality Commission earlier this month about the treatment of elderly people in the NHS in England. Unfortunately, we are now receiving a catalogue of such reports. In March, the older people’s commissioner in Wales told us that the treatment of some older people in Welsh hospitals is “shamefully inadequate”. The commissioner found instances of people not being helped to the toilet, poor communication and inadequate attention to patients’ need for food and drink.
One son reported how his mother begged for water after an intravenous drip was removed. Elderly patients in a Cardiff hospital day room were given tambourines to attract nurses’ attention. Again and again, we hear stories of patients not being treated with sufficient care, dignity and respect. Having said that, I should point out that there were also many examples of good practice. My own father has received good care in the Royal Gwent and Caerphilly District Miners hospital in recent years.
Nevertheless, given the blizzard of bad news on treatment for older people, the NHS Confederation succinctly says:
“We are well aware of the problems of poor care. What is less clear is why this has not always been tackled and what needs to happen to effect change.”
People have talked about a culture of indifference or, worse, of neglect, and ask what has happened to common compassion and kindness. It will take time to turn care around, but change must come. Recommendations in the report “Dignified Care?” include four key points: empowering ward managers to run their wards in a way that enhances dignity and respect, equipping staff to support people with dementia, prioritising continence care and looking further at whether there are sufficient numbers of the right kind of staff to care properly for older people in Wales.
We must ensure that we make things better this time. It is unacceptable that hospitals and care homes can flout their legal responsibilities to patients and residents and just be told to do better.
In Wales, the older people’s commissioner has reminded health providers that she has the legal powers to effect necessary change. Those powers must be enforced, key staff must be seen to be accountable and, most of all, patients should be heard. The Minister for Health and Social Services acted swiftly to increase spot inspections in Wales and I am pleased that the Secretary of State for Health has followed that course in England.
Strong professional leadership at ward level is of the utmost importance in securing change. We need the right skills mix in our hospitals and care homes to deliver the care that elderly people want and need. The involvement and feedback of patients and relatives is crucial, but we should not have to rely on relatives and friends to provide basic care, even if it were practical.
As someone who has spent some time working in the voluntary sector, I know that it can be a sensitive and sensible provider. The WRVS has informed us about some of its voluntary services on wards, which include befriending patients and help with feeding. I understand that it is keen to expand those services, which is something that I support.
Residential care is in some flux. One of the largest UK providers, Southern Cross, has collapsed. After a year of worry and anxiety for elderly people in its homes, we must now seize the opportunity to ensure that companies in the sector have a sound business model. They must invest for the long term and deliver high quality care for our elderly.
As a member of the Public Accounts Committee, I recently talked to Department of Health officials about the future of the social care market, which has changed dramatically in the past 20 years from a local market with single owners of individual homes to consolidation of ownership. Southern Cross owned about 9% of the UK market, and 30% of that was in the north-east.
I am not saying that all individually owned homes are perfect. Operation Jasmine is an ongoing investigation in Gwent, looking at the maltreatment of elderly residents in care homes in the late 1990s and early 2000s. The investigation is also looking at some small homes. The first prosecution of an owner and a manager is expected soon.
The position of Southern Cross, which was the subject of a number of takeovers and a massive profit grab by the venture capitalists Blackstone, is perhaps summed up by the reported admission of a former executive, who said:
“It really did seem like we were in a land flowing with milk and honey.”
The money men were working on a substantial projected increase in the elderly population. This week, for example, the Office for National Statistics predicted that the current number of people over state pension age will rise from 12.2 million to 15.6 million by 2035, which is an increase of 28%. The money men thought that with a growing elderly population and the subsequent rise in local authority funding, a rosy future with a rosy profit was guaranteed. The Department of Health’s director of care services said:
“Arguably, the people who invested took this to be an infrastructure project, like toll roads, rather than a care business.”
As someone once said, “If it looks too good to be true, it usually is.”
Southern Cross ran into the buffers, as the squeeze on local authority spending saw referrals and fees go down and occupancy rates drop to unsustainable levels. Given that the budget squeeze is likely to continue for some time, the stability of the care sector is of considerable concern. Yes, it is a business, but it is one that looks after frail and vulnerable people, so low cost and low quality is not an option, nor is it right for such people to live with the constant fear that they may have to move home; some certainty must be part of the care package.
I have said before that the Department of Health was slow to act on Southern Cross. I wish I was confident that Four Seasons, which is taking over a large number of former Southern Cross homes and which has more than £1 billion in debts, has a sound business model to deliver long-term care. It is unlikely to be the only operator under pressure as all private providers are dependent on revenue income from cash-strapped public authorities. Of course, as the PAC was told, the Department of Health does not commission services; such decisions are made by local authorities. None the less, the Department of Health sets the framework for social care providers and that must be robust.
The Department is now consulting on what measures it may need to ensure the effective oversight of the social care market. I hope that we will have more comprehensive measures in place early next year. The challenge for us now is to ensure that wherever our elderly are treated or looked after or helped to look after themselves, quality is embedded in the service, and dignity and respect are accorded without question. Together with our high-tech surgery and sophisticated drugs, we must ensure that we feed patients properly and give them the time, company and comfort they need, so that they can cope with the chronic ill-health, dependency, or terminal illness that will at some point come to us all.
It is a pleasure to speak under your chairmanship this afternoon, Mr Betts. I will try to keep my comments brief because I know that others wish to speak.
I congratulate my hon. Friend the Member for Stourbridge (Margot James) on securing the debate and on raising such important points. It is a tribute to her and the importance of the issue that so many colleagues have stayed behind on a day when the House is otherwise empty.
This is an important subject at national and local level. Mid Norfolk is a rural constituency with a very high ratio of retired and elderly folk. The subject is also important to the families and friends of patients and most important to the patients themselves, who often have no voice or people to speak up for them. My hon. Friend spoke eloquently of the problems that need to be addressed, including those of nutrition, courtesy, privacy and hygiene. I was struck by one or two of the statistics that she mentioned, particularly the 9 million meals left uneaten and the shocking number of deaths from malnutrition. Although one must not overstate the problem or get it out of proportion, which the media sometimes love to do, for those who are affected it is, as the Care Quality Commission report makes clear, nothing less than cruelty and neglect. As Nigel Edwards, the chief executive of the NHS Confederation, has said:
“It is of course important to put these 10 examples”—
from the CQC report—
“into perspective. The NHS sees over a million people every 36 hours and the overwhelming majority say they receive good care. But I fully appreciate that this will be of little comfort to patients and their families when they have been on the receiving end of poor care.”
At the risk of testing colleagues’ patience, it is worth highlighting some of the examples given in the CQC report and other reports, because we have had the privilege of reading them and other people may not have been able to do so. By including those examples in the report of this debate, perhaps we can help to highlight them. I was particularly struck by the following examples from the recent CQC report:
“The patient constantly called out for help and rattled the bedrail as staff passed by…25 minutes passed before this patient received attention.”
“We saw a staff member taking a female patient to the toilet. The patient’s clothing was above their knees and exposed their underwear.”
“Two members of staff who were assisting people with their meals at the time were having a conversation between themselves.”
Although in some ways the third is perhaps the least obvious example of poor care, it demonstrates what is often the source of patients’ frustration about lack of personal care when they need it.
Some other case studies were highlighted in the report of the health service ombudsman. I do not want to go through them all, but I shall mention two. The first was referred to as “Mrs H’s story”:
“When Mrs H was transferred from Heart of England NHS Foundation Trust to a care home, she arrived bruised, soaked in urine, dishevelled and wearing someone else’s clothes.”
The second case study was “Mr C’s story”:
“Mr C died two hours after undergoing heart surgery at Oxford Radcliffe Hospitals NHS Trust.”
Well, that happens, but the case study continued:
“His family was not told that his condition had worsened and staff turned off his life support, despite his family’s request to wait while they made a phone call.”
It is easy to highlight emotive examples that shock, but it is important that people’s attention is drawn to the specific nature of patients’ experiences, because it is in the details that we will begin to find the solution to the problems.
Two other issues that I have come across in my time as a parliamentary candidate and MP merit raising. The first is the difference between care and medicine. I speak as someone who has come to the House after a 15-year career in biomedicine, so I have some experience of the extraordinary advances that have been taking place in genetics, biomedical innovation, diagnostics devices and pharmaceuticals, but of course care and medicine are not the same thing. I have some sympathy with the comments made by my hon. Friend the Member for Stourbridge earlier about the occasional tendency in our modern health service to neglect, amid the busyness and professionalism involved in often extremely high-tech clinical care, some of the older skills of traditional nursing. I do not think that anybody has suggested that it is as straightforward as, “Modern nurses don’t care”, but given the specialisation and the clinical elevation of nursing we might need to consider whether we have left behind something rather more old-fashioned and traditional. In many ways, one cannot turn care into a specialism; care needs to be at the heart of everything that is done in the NHS.
The second issue is the integration of health and care. In my county of Norfolk—I dare say it is true of other colleagues’ counties too—we have an ageing population, and more and more of our constituents experience health and care needs that mean they often spend short spells in hospital before returning to the care system. That creates a number of challenging issues around the transition from health to care, and often back again, particularly relating to patient records and continuity of treatment. I know that the Government are looking at the integration of health and social care, and the commissioning reforms may provide some useful opportunities in that regard and for developing and accelerating best practice.
I will end with the observation that this topic is not one that lends itself to the creation of extreme differences between parties. It is important that today we have had a really good debate on cross-party terms and I suspect there would be wider interest in the House in taking the debate forward. I look forward to the Minister’s comments, and to reading those that I cannot hear myself as I may have to leave before the end of the debate, for which I apologise.
It is a pleasure to serve under your chairmanship this afternoon, Mr Betts. Like the hon. Member for Mid Norfolk (George Freeman), I must apologise that I have to leave at 4.30 pm, so I may not hear all the contributions that are made.
I congratulate the hon. Member for Stourbridge (Margot James) on securing this vital debate and on asking many important questions about quality of care and patients’ experiences of hospital. In addition, I welcome the contributions that have been made by other Members, which have been very important in fleshing out those issues.
I will make quite a brief contribution to the debate. Hon. Members have rightly recognised that, although there are some serious concerns about the care of older people within the NHS, there is also good practice that we can build on. So I will limit my remarks to giving one example of good practice that I hope will be of interest to hon. Members.
Earlier this year, I visited Queen’s medical centre, which is one campus of Nottingham University Hospitals NHS Trust. For those who are not familiar with it, it is a major acute and teaching hospital in Nottingham. While I was there, I visited ward B47, which is an acute medical ward for patients with dementia and delirium. Ward B47 has received a national health and social care award for mental health and well-being, and it was highly commended for putting patients and the public first.
While visiting ward B47, I met Professor Rowan Harwood, who is a consultant in health care of the elderly, Caron Swinscoe, who is the clinical lead for dementia, the ward’s matron, Ali Cargill, and Louise Howe, who is an advanced practitioner in occupational therapy, specialising in mental health services, and who spent 10 years working in mental health before she came to work on the ward.
Queen’s medical centre set up the medical mental health unit as part of a collaborative research project between Nottingham University Hospitals NHS Trust and the university of Nottingham, which was funded by the National Institute of Health Research and the Department of Health. The unit at Queen’s built on earlier work in 2005 by the Royal College of Psychiatry, which had shown that patients with dementia and delirium formed a large proportion of in-patients in acute general hospitals and that they had much worse outcomes than those in-patients with less complex problems. The unit was specifically designed to start to address that situation.
Ward B47 is a 28-bed ward, with three registered mental health nurses, a specialist mental health occupational therapist and an activities co-ordinator. Those staff members are working together with an existing multidisciplinary team, which includes an occupational therapist with experience in discharge planning. That new team was set up in January 2010. In addition, the environment of the ward was changed and all staff were given additional training in person-centred care.
In this debate, hon. Members have quite rightly spoken about the Care Quality Commission’s findings in relation to quality of care and about what are, in some cases, the extremely distressing experiences of their own constituents and families. Even where care is good—I am pleased to say that, in most cases, it is good—hospital admission can be a distressing and frightening experience. For older people with dementia, hospitalisation can be even more difficult and confusing. Families often report concerns and anxiety about the effect that a stay in hospital has on their loved ones, even where care is good.
My first impression on entering ward B47 was that it was different from other wards that I have seen. It was a calm but stimulating environment, and I will say a little more about the physical aspects of the ward. The most obvious difference was that there was a central activities room where a number of patients were taking part in activities supported by the co-ordinator and other staff. Even in the short period that I was there, I could see that the activity that was under way—patients were playing a game that involved throwing beanbags on the floor—encouraged physical activity. Obviously, people’s abilities were different, but the staff encouraged those who could participate to do so. The activity prompted conversation, interaction and engagement, preventing people from becoming isolated and allowing other staff to spend time with the more unwell patients who required more attention—a subject that other Members have touched on.
The ward’s staff explained how and why they were doing things differently. In making my remarks, I draw specifically on an article by Louise Howe, the occupational therapist, published in OTnews in May 2011. In it she states that the staff had observed that many patients lost their ability to function independently during a stay in hospital, and she gives a typical example. An elderly woman who had been living independently was admitted to hospital and, although forgetful, was able to carry out daily tasks such as preparing a meal. After a month, the occupational therapy team carried out an assessment and found that she was having difficulties recognising and using everyday items. The team was concerned that when she was discharged she would struggle to live safely in her own home—to cook and be around hot objects—and that prompted Louise and the OT service to come up with an approach to maintain patients’ abilities while in hospital. Essentially, they would assess patients’ level of function on admission—how able they were to wash, dress and self-care—and develop an individual care plan that all staff would work to, to help patients to maintain activities and skills. Patients would then be reviewed on discharge to see whether the actions had been successful.
The team also started to change the environment to make it more enabling for patients with dementia, with clearer signage on the ward, large clear clocks—people like to be able to assess how long things take—redecoration to make the individual bays look unique so that patients could distinguish their own beds, and memory boxes above beds to display personal items and make the environment more welcoming. The ward also commissioned photographs, showing staff and patients talking, completing self-care tasks and participating in group activities, and they were displayed around the ward to provide comfort and reassurance. Although that might sound like a small thing, staff and patients and their families reported that it was a welcome and positive move.
The occupational therapy team has strengthened links with community mental health services to ensure continuity of care after discharge, and has built links with bodies such as the Alzheimer’s Society, which provides a weekly advice and support service on the ward. The unit’s work is being researched by the university, which is looking at a number of measures—with a properly assessed control group—to compare mental state, delirium, pre and post-admission function, quality of life and carer feedback. The response from staff and visitors has so far been positive, the findings look good, and the team is looking to develop the ward further, for example by providing a more comprehensive programme of activities, including in the evenings when patients can become particularly distressed. It is also considering breakfast and afternoon tea groups to encourage patients to maintain their domestic skills, and the provision of sensory stimulation for patients who find interaction difficult and relaxation for those who find the environment over-stimulating.
I appreciate that my contribution has focused on one ward in one hospital and that there are many issues to address, but I hope that where there is good practice in the care of older people in an NHS hospital it can be used effectively to improve quality of care and patient outcomes across the wider health service and that we have the resources to enable that to happen.
It is a pleasure to serve under your chairmanship, Mr Betts. I congratulate my hon. Friend the Member for Stourbridge (Margot James) on securing this worthwhile and important debate.
The subject is of particular interest to me because the James Paget hospital in Gorleston serves my constituency as well as those of my hon. Friends the Members for Great Yarmouth (Brandon Lewis) and for Suffolk Coastal (Dr Coffey). As we have heard, the hospital has received two unfavourable Care Quality Commission reports and a red Monitor warning, and a third report is awaited. Although improvements have been made since the previous visits, there are still areas to address because elderly patients are not being given appropriate support with eating and drinking, and people in need of intravenous fluids are not getting infusions. I do not propose to go through the reports in detail, but I will highlight a few concerns that we need to address, not only in the James Paget but across the country.
My first point specifically regards the James Paget. The hospital’s main asset is its loyal and hard-working staff, including doctors, nurses, care assistants and the volunteers provided by the very good league of friends. There is a very strong team spirit, and it is vital that the staff, who want to provide the best quality care, are given the resources, training, support and leadership they need.
[Annette Brooke in the Chair]
My second point is about funding. A particular issue in an area such as ours—we have heard from my hon. Friend the Member for Suffolk Coastal—is that Suffolk and Norfolk is a popular area to retire to, and that puts pressure on the hospital. In Yarmouth and Lowestoft, there are pockets of deprivation, and the area is a popular holiday destination. Four or five years ago, when my late father was in the James Paget, he was probably one of only two local people on a ward of eight. That is an indication of the challenges that the hospital faces, and I hope that its funding generally takes that into account.
Hospitals need not only to tackle excessive bureaucracy but to look at areas of staff shortages. If the NHS is to survive, it must tackle social care, because otherwise we will face the prospect of more and more older people in hospital beds, creating a logjam and bringing the system to a grinding halt. It may well be that we should divert funds from the acute hospital sector and into adult social care to cope with the rising costs of health care and an ageing population; it is important to make savings wherever possible.
I do not like saying this, but there is a sense of déjà vu here. This debate is very welcome and we are all approaching the matter in the right way, but I sense that we have been here before. The CQC findings are similar in many respects to those in the Secretary of State’s 1998 report, “Not because they are old”, and there are parallels with the Patients Association study of two years ago. It is as if each new revelation creates a sense of outrage, and then nothing happens. We all have an obligation to ensure that this time is different.
There is perhaps an institutional ageism in our society to the extent that at times we do not understand the needs of the elderly, and are too condescending and dismissive. That needs to be replaced with a sense of kindness and compassion, with patients’ dignity respected. We should treat patients as people, not processes; perhaps in the past, in a drive to meet targets, patients were seen as procedures to be processed. There is perhaps a problem of patient care getting sidelined by targets, by finances and bureaucracy. The delivery of care has perhaps been regarded as a task to be completed, but it is a vocation, not a unit of work. More training and staff development is needed, with patient care at the centre of things.
On leadership and support, we must create a different culture in which good care flourishes. Leaders and managers in hospitals should work closely with staff in proper liaison. It should be a two-way relationship. Staff must receive the right support, and management must ensure that budgets are spent wisely.
Over the years, a poor understanding of malnutrition has crept up. There is a lack of awareness of the importance of good nutrition. Malnutrition costs the NHS £13 billion per annum. Inadequate food is a problem, as are inflexible regimes and a failure to meet basic physical care needs, which causes patients to become lonely and bored. Similar problems exist in some care homes; lack of attention to detail is a problem. Hospital food can at times be unappetising and unpalatable. We must examine food budgets closely. Are they too low? Should they be higher?
We need a fundamental look at the issue. The CQC does valuable work, but it cannot go back all the time, so we must consider giving patients an advocate who can fight their corner. Local HealthWatch organisations that carry out unannounced inspections have a role to play. Publication of malnutrition rates should also be mandatory, so that people can discover problems earlier and notify where they might be occurring.
Finally, I will mention an issue that is not the topic of this debate but is an elephant in the room: social care for our elderly in their last days. We need to integrate the health service and social care. The Dilnot report presents an opportunity to address a time bomb that has been ticking for a long time and that successive Governments have not grappled with. I hope that, in the spring, the Government will face up to reality and publish a positive response to what Andrew Dilnot said.
It is a pleasure to serve under your chairmanship, Mrs Brooke. I congratulate the hon. Member for Stourbridge (Margot James) on securing this important and timely debate. I beg your indulgence as I tell a personal story about my mum’s recent journey through the national health service. As many colleagues will know, my mum had a bad stroke in June this year, and we have had a bumpy ride over the past four months. I want to make it clear at the outset that the vast majority of care workers, nurses, doctors and other staff with whom we have come into contact have shown my mum a great deal of loving care, but she seems to have been let down by system failures.
Mum is 86, but before her stroke, she was still working, teaching three yoga classes a week, doing reflexology, driving her car and leading a totally full life. As hon. Members can imagine, it has been devastating not only for her but for all of us. After the stroke, she was first admitted to Luton and Dunstable hospital’s accident and emergency department. At about 4 in the morning, she was medically ready to be transferred to a ward and was taken up to the stroke ward. However, when we got there, we were told that there was no bed. We were not too fazed at that point—it was the middle of the night—so we accepted it, and she was transferred back to the emergency admissions ward. At the time, the medics were not sure that Mum would survive, so it was a difficult time for us.
By the following afternoon, we were getting agitated—[Interruption.] Excuse me, Mrs Brooke; you can tell how it made me feel. Anybody’s journey through the national health services in such circumstances is difficult, and ours has not been made better by what has happened to us. We were agitated by the following afternoon. Mum was still on the emergency ward, which was very busy and noisy. Eventually, we started the journey back to the stroke ward, to be greeted at the desk again with “Sorry, there’s no room.” At that point, I started to become six foot tall, thinking, “My mother is going to come into your ward.” Fortunately, a sister behind the desk treated us nicely, saying, “This woman will be admitted on to our ward.”
Some time later, concerned about her breathing, I called for a nurse. The nurse came in and said, “Well, you know she’s do not resuscitate, don’t you?” I said, “Yes, but I’m concerned about her breathing.” The nurse said, “Oh no, she’s fine. She’s actually in a deep sleep and things are good, but oh dear, I’ve not hung up the drip.” I spent the next half-hour holding up the drip so that Mum would get saline and holding Mum’s hand until the nurse eventually returned with the drip stand.
That is just the start of a chapter of system failure. It was a great frustration going to the desk and seeing all those people behind it, but being totally ignored. I did not know whether they were physiotherapists or doctors. When I said, “Mum needs the commode,” or “Please can you,” I was ignored. That was not just our experience but the experience of everybody on the ward.
No, indeed. That was what was said to me when I questioned her breathing. We knew that Mum was gravely ill and that they would not make extraordinary efforts to save her at that point, but the way that it was done did not make it the best thing that happened.
As I was saying, the great frustration was being ignored. One day I went to the desk, saw the doctor who was doing the round and said, “We really need to speak to you.” The doctor said, “I’m very busy at the moment, but I promise I will speak to you before I go home.” I went back to the desk a few hours later to discover that the doctor had gone home. We only got results by complaining. It was a difficult period.
Mum was on thickened fluids because she had difficulty swallowing. Each day when we went in, on her trolley would be a glass of ordinary, unthickened water. However, the good thing was that every day it was out of reach, so fortunately she could not choke on it. Then they complained that she was not drinking enough.
Food was a mystery. We would fill in the menu form, but each day it would be a lottery what turned up. Mum was on puréed food, but three times in one week, the lady in the next bed got no evening meal. Each time, they said, “Well, you didn’t fill in the form.” Her family said, “Yes, we did,” and they said, “Oh well, we’ll give you sandwiches.” Fortunately, that happened to Mum only once. Thank heavens my sister was there, because they said, “We’ll give her a sandwich.” My sister said, “Look on the chart over her bed—puréed food only.” Had she not been there, goodness knows what would have happened.
One day, Mum choked. They had got her out of bed, so she was sitting next to the bed, and she was choking. She was unable to ring her buzzer at that point, so another patient rang it, trying to get somebody to assist. Nobody came for about 10 minutes. The other patient’s young husband then had to assist my mother, mopping her up and getting her sorted out so that she was no longer choking.
For a few days, there was a lady in the bed next to Mum’s who sat on a pad that spoke every time she stood up. Clearly, she wandered, and they needed her to stay in place, but the message on the pad said, “Dear Mr Such-a-body, please sit down again and somebody will come to you.” Of course it was no trigger for that woman, as that was not her name. The name had not been changed. The lady opposite Mum could eat, but was not eating a great deal. She was not helped to eat or given prompts such as “Please have a bit more”; somebody would just come and say, “You need to drink a bit more,” instead of helping her.
I asked my assistant to send a card from my right hon. Friend the Member for Doncaster North (Edward Miliband) and the Chief Whip. I nearly asked for a card from the Prime Minister. I thought that maybe if they knew that I was an MP—I have never in my life told as many people that I am an MP as I did during that period—they just might give my mum a bit of extra care or show more concern. I even took in a box of House of Commons chocolates, as if to say, “Look after this lady, please,” but that did not make a great deal of difference. The staff did care, but the system was not in place. We felt that we had to make sure that, every day, somebody stayed for the full length of visiting hours.
After two and a half weeks, mum was transferred to Biggleswade rehabilitation hospital. Again, the staff were very loving, but they also let us down. They loved mum, and we felt that that was partly because mum is a proud, undemanding and polite woman. She was in Biggleswade for eight weeks and, again, we did not dare to not have somebody present to visit for a substantial part of the day.
Mum had pneumonia, along with the stroke, and after a couple of weeks at Biggleswade, she did not seem very well to us. We had to tell the staff that, despite the fact that she was getting close personal care at this time, mum was not well. They took her temperature and, yes, she had a chest infection. Treatment was good, but why was it us—she was in hospital—who had to raise the alarm? Mum was losing weight—she ended up losing 3 stone during this period. She was supposed to have protein drinks, but the drink only ever turned up on one day. Mum came to absolutely hate meal times at Biggleswade.
The second major incident was equally frightening for us. Mum had bumpers put on the side of her bed, to prevent her paralysed leg from getting caught in the bars. One night the bumpers were not put on and her leg got stuck. She, of course, did not realise this and it was only in the morning when she said that she was in extreme pain that it became apparent that this was why. Why were the bumpers not put on? Moreover, if it was a mistake, why did not somebody on their night tour know that the bumpers were not there? It is an 18-bed hospital, not an enormous one with hundreds of beds. Why, indeed, did the nurse in charge not check on the patients throughout the night? When we went in, mum’s leg was hugely swollen. The sole of her foot was purple. We are not medics—we did not know what was the matter—but we thought that something was wrong, so we raised the alarm again.
I want to tell this story because I think it is typical of other people’s experiences. Mum needed close personal care, so why did the carers, who were putting her in a hoist and changing her clothes and pad, not raise concerns about her leg being three times the size of the other one? The unit at Biggleswade is nurse-led, so a GP was called. He thought that she had a deep vein thrombosis and tried to get a scan the next day. He did not think that she should wait 36 hours, which was the time we would have had to wait for the appointment on offer. He thought that he had succeeded in getting a scan for her the next day, but, sadly, he had not, so we had a desperate day of trying to get mum scanned. We asked whether there was any other hospital that she could go to, and—remember that I am a good socialist, Labour MP—I even asked, “Can I pay?” I am grateful to mum’s MP, the hon. Member for South West Bedfordshire (Andrew Selous), who also helped and pulled out all the stops to try to get mum a scan, but we only managed to get her in the next day.
I asked to see the matron to see whether anything else could be done. Although I remained at the hospital all day, I was told that they had seen a posh car drive away from the hospital and had therefore decided that I had left—I am not too sure why they thought I drove a posh car—so the matron had left the site without seeing me. The medics were not too concerned, because they said that they had started treatment—a treatment that we were later told should not have been started before mum had had a brain scan, because she had had a hemorrhagic stroke.
I also discovered that there are only four slots for GP referral scans at Bedford hospital. The hospital serves many thousands of patients, so why are there only four slots for that huge population? We went to the hospital and another chapter of problems started. I will not bore everyone with the full details, but suffice it to say that there was a lack of communication, which resulted in mum missing her slot to be scanned, and a full day of a woman, frightened and in pain, sitting around in a hospital.
The overwhelming feeling was that everybody blamed everybody else. It was said that the day ward at Biggleswade should have sent her on a trolley. Somebody else should always have done something, but very few people said, “I will do something.” Mum was diagnosed with a DVT from toes to groin and was in the ambulance about to go back to Biggleswade while I was still in the hospital demanding answers from the doctors and asking questions. Fortunately, the consultant appeared at that point—I am not sure whether he turned up or was asked to come—and said that, because of the medication that mum was on, she should stay in and they should not send her home. That was the turning point in mum’s journey—good care and good treatment in Bedford hospital. She started to eat.
After two and a half weeks at Luton and Dunstable hospital, eight weeks at Biggleswade and one week at Bedford hospital, mum went into respite care in Swiss Cottage care home in her home town. What a difference. She is eating well, has started to put on weight and is starting to walk. She is making amazing progress and we hope that she will go home soon.
There has been only one bad incident in the care home. It asked a GP to visit and the one who was on duty—it was not her GP—refused to come, because he did not know her case, even though all the information had been sent to the GP. He referred her to Stoke Mandeville hospital for another scan—another day of pain and distress for this woman. They said, “She’s got a DVT,” but we knew that. That seems to be another failure.
I am grateful for the opportunity to tell my mum’s story, because, sadly, it seems typical of that of so many older people. It seems that if people have something that is wrong and treatable, they get good service from the NHS, but if they are older and just need care, the results are not so good. There also seems to be little consideration given to who that older person is or was; they just become “an old person.” Yes, she is 86, but my mum was a working 86-year-old, teaching yoga and apparently fitter than me—she was not just an old lady.
A GP in Biggleswade told me that my mother is lucky to have a family who have been fighting for her. It should not be that way. Every older person deserves to be treated with respect and care. I am grateful for this opportunity and I hope that, through all of our efforts, a real difference will be made to the treatment of older people.
It is a pleasure to serve under your chairmanship, Mrs Brooke. I am particularly grateful that you have allowed me to speak. I missed the beginning of the debate because my watch broke. It was immensely frustrating, so I appreciate you making an exception to the rule and allowing me to speak.
We have heard so many excellent speeches this afternoon and I agree with the contributions of all my colleagues. It is so refreshing to be part of this debate, which provides a contrast with yesterday’s debate on the NHS in the main Chamber. We are working together to highlight considerable concerns. I am sure that, considering the great passion that has been in evidence today, we can make a difference.
Other colleagues want to speak, so I will touch on only two areas that could be improved in the NHS. If they were improved, it could make a real difference in driving up the standard of care for elderly people. The first relates to improvements to the complaints process, and the second to a particular training need for people, whether they be doctors or clinicians, who come from overseas to work in the health service.
On the complaints procedure, highly effective organisations appreciate that every complaint is an opportunity to learn and improve. Such organisations have virtuous circles of continuous improvement, from complaint through to monitoring the improvements that they agree to make, to make sure that improvements result from every complaint that is investigated.
I have read with interest the recently published report of the parliamentary and health service ombudsman, Ann Abraham, “Listening and Learning”. It is a review of NHS complaints handled in England from 2010 to 2011. It is a hard-hitting and informative read. Ann says:
“In last year’s report…I concluded that the NHS needed to ‘listen harder and learn more’ from complaints. The volume and types of complaints we have received in the last twelve months reveal that progress towards achieving this across the NHS in England is patchy and slow.
This report shows how, at a local level, the NHS is still not dealing adequately with the most straightforward matters.”
We have heard that today. She goes on to say that two particular themes emerged. First, the most prevalent reason for complaints was a lack of effective communication, as every speaker today has highlighted. Poor communication can have a serious, direct impact on patients’ care and can unnecessarily exclude their families from a full awareness of the patient’s condition or prognosis. Secondly, in an increasing number of cases, a failure to resolve disagreements between patients and their GPs has led to their removal from the GP list. Her report cites a particularly harrowing example of somebody—a very vulnerable and elderly person—being excluded from the GP list in the last few days of their life.
More positively, Ann Abraham notes that there have been improvements in the attitudes of NHS senior management when tackling the issue of complaints handling and that there has been more partnership working with other parts of the NHS, such as the Care Quality Commission. However, clearly, much more effort needs to be put into showing NHS staff how complaints can drive up standards of patient care. The majority of doctors, nurses and other clinicians in the NHS in Cornwall, and I am sure around the country, get job satisfaction from delivering high-quality care to their patients. I have listened to nurses who suffer when they work in wards that are poorly led and monitored, and where bad practice is ignored. Worse still, when they try to tackle the situation by reporting their concerns and even making protected disclosures, nothing happens.
In remote and peripheral parts of the country, such as Cornwall, there is only one acute hospital, so staff are very reluctant to complain because there is nowhere else for them to go. That is stressful for staff and, obviously, far from good news for the patients on their wards and under their care. I am pleased and encouraged by the Care Quality Commission’s work in Cornwall. When all parts of the NHS and other care providers are registered, so long as they have the necessary resource, they will be highly effective in driving up standards of treatment and care. I would like the Care Quality Commission to have a far greater role in the NHS complaints process—for example, it should be given copies of all complaints, all protected disclosures and all death reviews in hospitals. That information is vital to helping the CQC to assess risks and manage improvements.
Where a complaint has led to an improvement being agreed, the CQC should have the opportunity to visit and spot-check to ensure it has been implemented. If the CQC were more involved in the complaints process, the quality of care and services, as well as job satisfaction for NHS staff, would be improved. The poor quality of care an elderly person might have experienced, either at home or in residential care, should also be dealt with by complaints processes that involve the CQC.
A more public communication of complaints data will also help to drive up standards of care and will give patients more important data upon which to make a choice. I am pleased that, from this month, the Department of Health has committed to publish complaints data by hospital, and that foundation trusts will also shortly be required to provide information on complaints. Like Ann Abraham, I hope that, following the Government’s consultation “An Information Revolution”, a framework for making that information available will be published. It is important to have standardised indicators and measures for both complaints and lessons learned, so that patients and staff can compare like with like. I hope that the Minister might be able to comment on that today.
The second point is about staff who come into the NHS from overseas and who have been trained overseas. Much has been reported in the media recently about the poor language skills of some of the doctors, nurses, clinicians and care workers who come into the NHS, and the problems that that causes. That is an important issue but the attitude of such staff, especially towards older people, is as significant.
Although I appreciate that the training of doctors is not the responsibility of the Department of Health, it could be part of the commissioning of services. Guidelines could be given to commissioners not only on training, but on ensuring that people coming from overseas had effective training on how to treat people with respect and dignity. The value assigned to elderly people is different in different cultures around the world, and that needs to be addressed when employing people in the NHS. I am aware that many colleagues want to contribute, so I shall conclude my comments there.
I congratulate the hon. Member for Stourbridge (Margot James) on securing the debate and thank the Backbench Business Committee for timetabling it. There are few issues that mean more to me or make me more angry than the poor treatment of older people, especially by our NHS. Therefore, it is highly important that we focus on that today.
I shall begin where other hon. Members might not have had time to go—by questioning our values. The hon. Member for Stourbridge listed societal problems as being one of the causes of indignity in hospitals and, when I intervened to ask her about that, she said that she did not have enough time to go into the subject. I hope I can assist her by taking us on that journey.
I am afraid that I shall start by disagreeing with the hon. Lady. I find it hard to believe that there is a lack of moral value or preference in society. Part of the problem is that those values are not made explicit often enough. We have talked much about dignity today. That word is often used, but rarely explored. I question and doubt the point made by the hon. Member for Truro and Falmouth (Sarah Newton) about older people being treated differently in other countries. If that is the case, it is incumbent upon us as politicians to make our values absolutely clear. In many ways, the national health service is, for Britain, an expression of our moral choices and preferences. Whether or not we talk about the NHS in those terms, that is what it is.
Let us begin by asking what we mean by “dignity.” It means inherently respecting the other person because of their humanity. In practice, that means demonstrating they are listened to, cared for and thought of, no matter who they are or what their personal circumstances are. Let me quote from the CQC report to give an example of what I mean and why it is so important that we make that absolutely explicit. In the report’s overview by Dame Jo Williams, she mentioned that they found cases where they believed that staff stripped patients of their dignity. She says:
“People were spoken over, and not spoken to…left without call bells, ignored for hours on end, or not given assistance to do the basics of life.”
When we talk about dignity, that is what we really mean. I find it hard to believe that we live in a Britain where most people would walk past, look the other way or not consider the needs of somebody who is extremely vulnerable and stripped of the basic necessities of life. The vast majority of people in our country would consider that situation to be utterly intolerable.
The question is: what is going on in the health service that leads us to see cases in our surgeries and examples among our families where people are bereft of their dignity? Given that we set such high moral value by the appropriate respect given to people because of their inherent dignity, what is going on in the health service that allows such a situation to occur? I accept other hon. Members’ points about the level of frequency and the commitment of staff by and large, and I was also most taken by the remarks of my hon. Friend the Member for Nottingham South (Lilian Greenwood), who is no longer in her place, about the best practice demonstrated to her. Given that we know what the right answer is, we need to consider what happens when there is a failure.
I thank the hon. Lady, who spoke so well and so bravely earlier, for her intervention. I will come on to describe the differences within hospitals—a point at the heart of the debate.
Last year, the Wirral University Teaching Hospital Trust experienced some of the worst staff survey results in England. They were awful. The percentage of people who would recommend our local hospital to a member of their family was disturbingly low. I know I speak for other hon. Members in the area when I say that we are extremely concerned about this. The trust has a plan of action to try and put this right and there are many examples of the best quality of care being given to my constituents. However, some wards have been very poor. What we have observed locally relates exactly to the point raised by the hon. Member for Suffolk Coastal (Dr Coffey). Some wards are very good and some are extremely poor, and the CQC report also found that. Some of the places of most concern also had very good practice, so this is a problem.
We ought to ask the following questions about staff in the NHS, and I think that they should ask the same questions of themselves. The first question relates to the point that I started with: do they have the right values? Do they make the right moral choices? Do they have the right preferences? By and large, I think our answer would be yes. I do not believe that people in this country somehow just do not care—I think that that is wrong. The second question is: are NHS staff empowered to make choices in line with those values—the basic right to dignity and sense of humanity that we want them to? Are they empowered? Finally, in line with the points that have just been made, are they accountable if that does not happen? That is a crucial point.
The Front Line Care report is an important report written under the previous Government about the future of nursing. There is, perhaps, a missed opportunity. It covers, in detail, many of the questions that we have about nursing care. My mother was a nurse. Her line on nursing is that a nurse’s job is whatever the patient needs. That coheres entirely with both the Front Line Care report and the CQC report, which points out the problem alluded to by other hon. Members. Dame Jo Williams states that care seems to be:
“focusing on the unit of work, rather than the person who needs to be looked after.”
We need staff who are empowered to provide person-led care that looks at the needs of each person, and delivers for them what they need in the health service.
There is, of course, the question of targets. The Government have moved towards dropping some of the waiting list targets that were in place under the previous Government. Is this the kind of thing we can have targets for? I am not sure. However, I know that we know good quality when we see it. If the model of staffing for the dignified and respectful care of people is right, then that will drive up the quality of experience they receive. Leaving aside whether we have targets, quality of experience can definitely be monitored. There are some difficulties relating to monitoring older people, not least people who die in hospital. It can be very difficult to ask for feedback about the death of a loved one, but we need to find a way of asking. A good death is at the heart of what it means to be a dignified person. I encourage all hospitals to think carefully about how they ask for feedback from the relatives of a patient who has died. Even in the case of an older person with dementia, how do we get feedback on how the NHS has treated them?
As politicians, we need to back nursing staff and doctors. At the beginning of my speech, I tried to be very clear about the values that we espouse and I hope that they are shared across the Chamber. Those values give people absolute faith about what is expected. We can be clearer about the standards of care that we expect. I have concerns about systems, such as the red tray one, which rely on a tick-box culture, rather than saying, “Here is the standard that we expect people to live up to and it is your responsibility to do so”. How people in different wards meet those standards would be different, but they must meet them.
I would set the following test for the NHS. I believe in the NHS not merely through custom and practice, but as an article of my political faith. It is a fundamental expression of our values that everybody should be looked after if, through no fault of their own, they become unwell. Everybody should be taken care of. That means that if one person is not taken care of in the NHS—whether they are related to us, or nothing to do with us—in the way that we would expect for a member of our family, then that is not good enough. We should articulate that value. I hope—and know, in my case—that local leaders of hospitals share the belief that we should care for people in the NHS as though they were members of our family and give them the dignity to which they have an absolute moral right. We need to articulate those values and then make people empowered and accountable to living up to them in the NHS.
It is a pleasure to serve under your chairmanship, Mrs Brooke. I thank the Backbench Business Committee for allowing us to have the debate. In particular, I thank the hon. Member for Stourbridge (Margot James) for securing it. I also want to thank all other hon. Members who have spoken and given passionate, heartfelt and thoughtful contributions.
Hon. Members from all parts of the Chamber have spoken with one voice. It is completely unacceptable for any older person to receive the appalling standard of care that we have read about in the CQC report and in the ombudsman’s report. We have seen that appalling standard of care in our own constituencies. My hon. Friend the Member for Bolton West (Julie Hilling) has seen it in her own family. Although we may not have seen as poor a standard of care as she did, I am sure that many of us have been concerned about the care given to our own families. I would like to consider some potential causes of those poor standards of care, and talk about possible measures to tackle them and to ensure that every service matches the best standards.
It is important to look closely and carefully at this question and to avoid thinking that one issue, one group of staff or one set of problems is to blame. While there are some straightforward, practical steps that could be taken immediately, there will not be one simple quick fix that will solve the whole issue. There are deeper and more complex issues that are far harder to address. I will talk about five areas: staff levels and resources; staff training, which many hon. Members have spoken about; culture and leadership; the regulation of the NHS; and deeper issues that are very difficult to address.
Several hon. Members, particularly at the beginning of the debate, raised the issue of staffing levels and resources. If we talk to individual members of staff or organisations such as the Royal College of Nursing, they say that the issue is of concern. Staff to patient ratios were referred to by the hon. Member for Stourbridge and the hon. Member for St Ives (Andrew George). Peter Carter, who runs the RCN, gave me a stark example. The figures are rough and not perfect, but he said that paediatric and children’s wards have one nurse for every four patients, while in the wards that specialise in care for older people the ratio is around one nurse for every 10 patients. Elderly, dependent patients have different needs from sick young children, but in many ways they are just as challenging, so we need to look at that, particularly because, with an ageing population and some of the problems in social care, more sick elderly patients are ending up in hospitals, many with not only dementia but two or three other health problems. That co-morbidity issue will be important as we see hospitals with big financial challenges, which we will over the next couple of years.
On staff training, we often hear commentators or senior people in the NHS, frequently medics, who question whether moving nursing towards being a degree profession has been an entirely good thing. It is vital to get the right balance between academic and practical elements in nurse training. Degree courses have been around for many years—40, I think. As many hon. Members have said, we see differences between and even within hospitals that are using nurses with the same qualifications, often from the same universities, and some have their problems and some do not. We need to look at the balance, but we should not think that that is the entire cause of the problem. A lot is down to the culture created in wards, which I will say more about in a moment.
Concerns have been expressed by many hon. Members today, the media and NHS staff about health care assistants. Health care assistants in wards provide more and more of the care, some of which is intimate, such as feeding older people or helping those with continence problems, but it is a positive development. As other hon. Members have said, our staff have the right values, and that is partly about the training they get. I think the hon. Member for Stourbridge said that health care assistants do not get any training and are not regulated, but they do, or should, get training from their employer, the trusts. Such training can be patchy, and we need to look at that.
In 2003, I called for the regulation of health care assistants—as many people did, way before me—in a project I did called “The Future Healthcare Worker.” If nurses are to take on some of the more clinical roles, and health care assistants more care, we need to look at that issue. I had hoped for more progress on that under the previous Government. It would be interesting to hear from the Minister the current Government’s views on regulation. There are all sorts of issues around time and cost—for employers and individual staff—but it is something we need to look at.
Culture and leadership are woolly words, but in practice we know when we see good culture and good leadership. My hon. Friend the Member for Wirral South (Alison McGovern) made this point. What is it on the ward that matters above all? Yes, it is about how long it takes to be treated, whether operations are a success or whether medicine is taken on time, but it is also, crucially, about the experience of the patient, whether they and their families feel that they have been given enough information and the time to think about it. When the information is given can be important. We have all been in situations where the doctor has said something quite shocking and we were not prepared for it. What matters is the simple things such as whether the patients are covered up when they go to the toilet and cleaned effectively afterwards.
There are places where the patient’s experience is at the top of the agenda, not only of the individual ward but of the hospital as a whole. Simple and straightforward surveys, developed by organisations such as the Picker Institute, can help individual organisations and services to get that across.
Another thing about culture is a bit more tricky and concerns how we build a team and being open to questioning. In a team, staff should value each other’s different experiences. That might not be the case with some of the old-fashioned hierarchies in a hospital—doctor, nurse, care assistant—where they do not dare question one another. Teams need to value each other’s skills and experiences but also be open to questioning.
That is absolutely right. It is not that everyone has the same skills and experience, but that all those different skills and experience are important. In a proper culture of learning, mistakes can be admitted, because we all want to learn from them to ensure that they do not happen again. We need to see not only the different health professionals as part of the team, but users and families too. Peter Carter of the RCN raised the issue of families being involved, and it was sad that all over the papers he was reported as saying, “Come in and care—it is up to you to care for members of your own family.” What we need, though, is for families to be part of the process, particularly if their relatives are elderly patients suffering from dementia. Family members know them best. We might not be able to hear what they are saying but their family will know how they react, and whether they like or dislike something.
Such a culture and such leadership need to be in evidence not only on the ward, but on the board—a point made by the hon. Member for Stourbridge. As the boss, the board should want to know what is happening on the ward and its members should be getting the surveys and patient feedback. As with Members of Parliament, hopefully, what they will most want to know is what individual constituents think of them. Accountability is vital, from the top down. Also, in particular for old people who might not have family members nearby, the idea of volunteers who can be advocates and part of the process is important.
On regulation and the Care Quality Commission, I am concerned about the issue. More could be done immediately. The CQC has an important role to play, but I want to be clear that responsibility for the quality of services lies with the providers and not with the regulator. However, people want to have confidence that, if the CQC says that somewhere is okay, it is okay and, if it is not okay, that the CQC will go back and ensure that it is sorted out. I am concerned that, almost six months after the initial inspections, the CQC has not been back to a third of the hospitals it said in its report were failing to respect and involve older people, and it has not been back to two thirds of the hospitals that were failing to meet nutritional needs. I have written to the CQC, which has not written back, but it said on the phone that it had received written reassurances. That is not good enough. It should be going back to those hospitals. I am keen to hear from the Minister whether he could take action to ensure that we know which hospitals have not had a follow-up and what the timetable for action is.
There are clear national guidelines for people who work for public bodies such as the council or the NHS. There are guidelines on raising the alert and referring a person immediately—within one day—if it is thought that they are vulnerable or at risk of neglect or abuse. I have asked the CQC whether it referred people, or whether it required the hospitals to do that. If someone has seen children at risk of neglect or abuse, action would need to be taken or they could face the legal consequences. I am concerned about that matter.
I have spoken longer than I intended. I want to finish by addressing what I call “deeper issues”: our model of health care, the nature of medicine and the way we as a society treat older people. When our NHS was established, our population had very different health problems. People needed episodes of care for acute conditions that could be treated and increasingly cured. Our health services were based on the model of individual district general hospitals. However, we have health problems now that are related to people living longer with long-term and chronic conditions. Improving health is no longer solely about needing episodes of acute care that seek to cure people. It is about increasingly helping people to manage their long-term health problem, and, when they are very old or suffering from dementia, helping them to live to the end of their days as comfortably as possible.
Our model of health care has not kept pace with changing needs. One third of hospital admissions are for people over 65, but, because on average they stay in hospital twice as long, two thirds of hospital beds have an older person in them. Hospitals are not the place to care for older people, but hospitals are where we care for them. We must change that situation, which means shifting services out of hospitals and into the community. We need to focus more on prevention and joining up with social care.
There is a big challenge for medicine. We have talked a lot about nurses, but not about doctors’ mentality. They are trained to cure. There is a big challenge for doctors as well as nurses as our health needs change. In too many places, doctors are still at the top of the hierarchy. They are the ones who help to determine the shape of care. It is important to look at their changing role, too.
I want to talk about how we as a society treat older people. I hope we will have a proper debate about that one day. I want to say two things. First—I think other hon. Members have mentioned this—we are not used to seeing people get so old. It is quite a recent thing to see people living for such a long time, often in pain, and it is very painful for families, particularly if they see people whom they love suffering with dementia. Society shuts older people away too often. We say, “You’re just getting old” or we prefer that they are not seen and not heard. In other countries, it is not like that. Older people feel more part of the community and they are perhaps more visible than in this country. I can give a simple example. Care homes in Spain do not have opening hours—they are simply open—and people see them as part of the community.
The issue is about how our services cope with an ageing population and how we treat older people. If someone is very old and slowly dying, including from something such as dementia, which is awful to see, we need to find a new way to deal with that.
I start by thanking the Backbench Business Committee for scheduling the debate and the hon. Member for Stourbridge (Margot James) for securing it. We have heard personal testimonies and powerful speeches today. There have been thoughtful contributions and I want to make sure that the debate is seen by colleagues at the CQC. The relevant national clinical directors, the chief nursing officer and the chief executive of the NHS ought to read the report of the debate because it encapsulates in a very powerful way the challenges, as well as the opportunities to move on and make a difference for the people we are here to serve.
I want to address the problem and then describe some of the things that are happening and discuss what more needs to happen. Whether in the NHS or in our wider care and support system, poor quality care can never be acceptable and should find no hiding-place in our country. Many hon. Members have rightly expressed their serious concerns that such shocking and neglectful care can be—or appear to be—tolerated within our NHS, and that kindness and compassion can go missing on some wards. The hon. Member for Bolton West (Julie Hilling) described her journey and the way the system almost seems to have imprisoned people with good intentions and disempowered them. The point about empowering staff to live their values in their practice is an incredibly important one.
I will not speak to the social care piece of the debate in great detail today. The Backbench Business Committee has scheduled a debate on social care on 10 November, and I look forward to that broader debate. I will talk about the problem that we have been wrestling with today. Sadly, it is not a new issue. The ombudsman report, “Care and Compassion”, is just one in a long line. Evidence of poor or variable care for older people can be found in major clinical audits on continence care or falls and bone health undertaken by the Royal College of Physicians; in the work of NCEPOD—the national confidential enquiry into patient outcome and death—and its inquiry into pre-operative care for the over-80s, chillingly titled “an age old problem”; in the findings from the national hip fracture database; in the parliamentary inquiry into the human rights of older people in health and social care; in the many reports by charities such as Age UK and the Alzheimer’s Society on acute care and nutrition; or in the Mid Staffs inquiry. Taken together, those reports, audits and inquiries, which go back years not months, paint a disturbing picture that quite rightly has been rehearsed here today. They demand action.
Some people try to reduce the issues to problems that need simplistic solutions, of which there are none. Some people see the issue as an opportunity to make criticisms of modern nursing or the role of health care assistants, which misses the point of so many of the reports I just listed. Such issues do not have a single cause, so there cannot be a single magic bullet solution. However, I am clear that we have to move on from merely describing the problem. There is an almost constant cycle of revisiting the problem, but never actually solving it. We need to identify steps to solve it.
I shall outline some of the steps the Government are taking in concert with others—it cannot just be governmental action—to stamp out poor care and to embed a culture of quality care, and zero tolerance of behaviours and systems that do not facilitate that care. I cannot cover all the actions that are taking place; only some. The level of non-compliance uncovered by the CQC inspections in 100 hospitals was inexcusable; in my view, there are no mitigating circumstances that can relieve medical staff of the duty they owe their patients. I agree with the hon. Member for Leicester West (Liz Kendall), who said that follow-ups by the CQC need to be rapid and proportionate. Matters cannot be left unanswered. Once concerns have been identified, they need to be properly followed up to ensure they are addressed.
My hon. Friends the Members for Suffolk Coastal (Dr Coffey) and for Waveney (Peter Aldous) mentioned the James Paget hospital. I shall not usurp the role of the CQC, but its report has made it clear that the trust could face prosecution or suspension of services for the failures that have been identified. We must now await the next report, and expect speedy and timely action from the CQC as it discharges its responsibilities.
As part of the next wave of inspections announced yesterday by the Secretary of State, the CQC will carry out inspections not only on a nine-to-five, Monday to Friday basis, but outside normal hours so that we get the fullest possible picture. That is essential and it is right for that point to be raised. The CQC will undertake 500 inspections, also outside normal hours, to look at residential care for elderly people. It will look at the care and welfare of service users and their nutritional needs, which will shine an important light on issues of dignity and care in the sector. The CQC will not only highlight care homes that are not performing well; it will put those that are as they should be into the spotlight to take the applause they deserve when they get it right.
Let me put the debate into context. There is nothing inevitable about illness and disability in old age. Dementia or falling over are not normal parts of ageing; illness and ageing are not synonymous, and we must get that point across when designing our systems. That does not mean that an ageing population poses no challenges to our health care system because it does, but it is also a cause for celebration. The age shift taking place in our society is one of the biggest challenges we face, and it is right that Parliament should spend more time debating it.
Caring for older people is the everyday business of the NHS and a core part of what it does. People over 65 account for 65% of hospital admissions and 70% of bed days. We must, therefore, look carefully, critically and constructively at how the model of care needs to adapt to address those needs. We have an episodic model but we need one that reflects co-morbidities, complexity and long-term conditions. That is the challenge, and it requires the debate that we shall have on social care, which is the other side of the same coin.
The hon. Member for Nottingham South (Lilian Greenwood) referred to dementia. We estimate that a quarter of people in every adult acute hospital suffer from dementia or confusion that is often undiagnosed and too often ignored. That failure to diagnose can add days to the length of a person’s stay in hospital, and create additional distress for the patient and their family. The hon. Member for Waveney spoke of a sense of déjà-vu, which I feel that I have shared for many years. In opposition, I repeatedly raised the issues under discussion and argued that at their root lie ageist assumptions and practices. Time and time again, I pressed for a systematic approach to ageism in the NHS, and for the law to state beyond doubt that ageism is unacceptable; one of my first acts as a Minister was to rule out any exemptions from the age discrimination duty for the NHS. In future, the arbitrary use of age cannot be used in the NHS as a means of limiting the care and treatment that older people receive.
The introduction of the equality delivery system across the NHS, involving leadership at all levels, means that for the first time a mechanism is in place to challenge and change the culture and behaviours that allow ageism to prosper. I greatly welcome the initiative led by the NHS Confederation, the Local Government Association and Age UK to look at issues of dignity, and the Department is working closely with them on that. We expect, however, that the work will look beyond analysing problems; we have done too much of that and there are too many reports sitting on shelves. The problem has been analysed but we now need practical steps to deliver change.
A debate such as this must go beyond discussing the problems; we must highlight the stories that are told less often. In many places, care is exceptional and excellent, and 45 of the hospitals inspected were fully compliant with the essential standards. Many NHS trusts take care seriously and want to get it right for older people. At University Hospital Southampton NHS Trust, for example, the Southampton meal-time assistance study is evaluating the effectiveness of additional help from volunteers at meal times on acute medical wards for older people. University Hospitals Birmingham NHS Trust is implementing a systematic trust-wide approach to improve dignity, which includes using the stories of carers and patients—the story related by the hon. Member for Bolton West would be relevant—in its clinical governance arrangements and regular dignity rounds. The Department has funded work by the Royal College of Nursing on improving dementia care in general hospitals. That initiative was launched in September, and the RCN spelt out its commitment to the care of people with dementia and noted the critical factors essential to delivering good quality care.
There is, therefore, no shortage of tools, guidance, ideas or initiatives that can be taken to tackle these issues. If we get safe and dignified care right for older people, we will get it right for the majority of those who use our health service. It is not always about money but about attitude, approach and doing things differently. Often, it can be something simple such as putting ourselves in the patient’s position and looking at the service through their eyes. At Sheffield’s Northern General hospital, for example, patients and carers were concerned because they could not tell the difference between different types of staff on the ward, so staff put up colourful and simple posters around the hospital that identified them by the colour of their clothing. That suddenly lifted a barrier to patients’ understanding of what was going on around them, and made a real difference.
Several hon. Members have mentioned staffing levels, which is an important matter. The CQC expects registered organisations to ensure that they have enough skilled and trained staff to deliver the care expected of them, and failure to comply carries all the relevant enforcement powers and consequences. The RCN has published guidance on staffing ratios, and we expect that to be consulted and used by nurse leaders, who should have the freedom to agree staff profiles for their organisations. We all recognise, however, that it is not an exact science, which returns us to the quality of leadership and culture, which many hon. Members mentioned.
The role of nurses and health care assistants has been mentioned by several hon. Members. At the heart of good nursing lie values of compassion, respect for the rights of the individual, empathy and kindness. The principles of nursing practice are clear and the Government believe that nurses must be recruited for their values, trained for their skills and empowered to practise their values in their work. That means that universities and NHS organisations must work together on the selection of students to ensure that requirements for education and practice are met, not least because the pace of technological and pharmacological change demands higher levels of knowledge and skills to deliver high-quality patient care. Having a degree-educated work force does not mean placing technical competence ahead of values; that is a key point in ensuring that caring does not turn into the specialist service that some hon. Members fear it is becoming.
Caring demands high standards, leadership, and a readiness to challenge poor practice and demonstrate good practice. I will follow up the suggestion about meeting the Nursing and Midwifery Council, and I will ask my officials to discuss the matter with the Minister responsible for nursing, my hon. Friend the Member for Guildford (Anne Milton), who I know takes a close interest in such issues.
The role of health care assistants has been raised, and it is worth noting that the Government have put into legislation for the first time the power to regulate health care assistants. We are breaking new ground, although I am sure some will feel that we are not doing so quickly enough. We are taking a measured approach, however, by legislating for the Council for Healthcare Regulatory Excellence to establish a voluntary registration scheme that will set a benchmark for training, conduct and competence. However, it is our view that it is right to place responsibility fully and squarely on employers to decide whether to select staff on the basis of their registration. They must ensure that staff have received the necessary training for the role that they are undertaking.
The hon. Member for Wirral South (Alison McGovern) made a very important point, which I encapsulate in this way. We have an NHS that all too often can be described in industrial process terms. We need an NHS that is all about personalisation and that is personalised to the individual. That is an important part of the transformation that we need.
Leadership has rightly been talked about a lot in the debate. It is critical. Directors of nursing, medical directors and other health professionals must deal with the issues raised in the CQC report. Just as the CQC has turned a spotlight on dignity and nutrition, so too must every NHS trust look at the report and take a long hard look at itself and the stories that this debate has highlighted. Too often after things have gone wrong, we learn time and time again—sadly, the debate has underlined that point—about the staff who tried to alert senior clinical colleagues or managers only to be ignored or, even worse, victimised, or about the patients and families who have been on the sharp end of appalling care and who are marginalised, with their experience not being used to challenge and change poor practice.
We all have such cases in our mailbags. We have all had constituents in our surgeries who feel let down because they have not been listened to and who do not feel that there has been any learning as a consequence of their experience. There can be no place in the NHS where staff feel unable to speak up when patients are being put at risk, and no place in the NHS where the voice of patients and carers is not heard loud and clear.
When the hon. Member for Worsley and Eccles South (Barbara Keeley) talked about complaints handling, she made very important points. Getting redress or an apology should not be a battle. People should not have to feel that the lessons are not being learned. It must be staff on the front line who work on the wards every day and see poor care—patients not being fed properly, privacy neglected, poor continence care or, as the hon. Lady said, pain relief overlooked—who change things for the better. That is why we are placing all providers under a duty of candour and why we are strengthening the NHS constitution to put beyond doubt the duty on managers to support staff who raise concerns about the quality of care. That point was touched on in the debate. We need to send a clear message that managers must support staff who raise concerns about the quality of care. It is also why we are establishing HealthWatch England and local HealthWatch to champion the interests of patients and carers.
There can be and should be no hiding place for poor care. The CQC inspections that the Government ordered are part of the work to take that agenda forward, but are by no means all of it. There is no magic bullet solution to this problem. We need a wide range of things: an effective inspection and regulation regime, which measures what matters to patients and carers and then takes action; guidance on what good practice looks like—for instance, the range of National Institute for Health and Clinical Excellence quality standards and guidelines on older people’s care; and the systematic involvement of older people and carers in the design of services from the outset.
We need greater transparency on complaints. We must ensure that we get it right the first time and that we value complaints as a way of learning and changing the way organisations and leaders in organisations behave. Feedback is needed to improve services. People must seek continuously to improve services. Another element is use of the law. We sometimes debate human rights in a very negative way. In this area, human rights are central, and we must deliver them for older people. We must use our equalities duty legislation as well.
Another requirement is effective advocacy and leadership from professions at every level—at ward level, at institution level and at the level of the Royal Colleges and specialist societies. We need a work force supported with the training and skills to make them fit to care for an ageing population. That is a new challenge, and we need to adapt to meet it. Other requirements are advocacy and support from the voluntary sector and—notwithstanding some of our debates about system change—system incentives, such as outcome indicators and best practice tariffs to drive the right behaviours. We need much more transparency around performance data, such as those provided by CQC inspections, audits and satisfaction surveys. We need a greater focus on integration—many hon. Members touched on this—so that older people are in hospital only when they need to be. Hospital is not the right place for most older people in most circumstances.
This is about culture and systems. The Government recognise that. We know that we cannot do it on our own. We are working with others to make the changes that are needed. Yes, there has to be action now. The Government are taking immediate action by casting the spotlight where it needs to be. We must then sustain the action to get the transformation that is essential to delivering quality of care and the dignity and rights of older people in the NHS and anywhere else they need care.
It is a pleasure to speak under your chairmanship, Mrs Brooke. We have had an extremely illuminating and, at times, distressing debate. I am very grateful to all hon. Members who took part, including those who have had to leave, for bringing so many aspects of this difficult problem into the open and for making so many constructive suggestions about how we might improve things. I should like to set out a few of the lessons that I have learned from hon. Members during the debate.
My hon. Friend the Member for Suffolk Coastal (Dr Coffey) set an example of the importance of the job that we sometimes have of challenging the institutions on which so many of our constituents depend. I wish her and my hon. Friend the Member for Waveney (Peter Aldous) every success in dealing with the hospital on their patch and working with the CQC to bring about a quicker resolution to the problems that they encounter there.
I found noteworthy the issues facing rural areas to which my hon. Friend the Member for Suffolk Coastal referred, because I represent a suburban area. It is interesting to note that ambulance response times can be so long in rural communities. It is very important that the NHS is able to be flexible enough to cope with all the communities in our country.
The hon. Member for Blaenau Gwent (Nick Smith) gave us the benefit of his experience as a member of the Public Accounts Committee. I was pleased that he focused so much on the residential home sector, which is so relevant to the lives of many older people and about which a similar level of concern has been expressed in many reports. I was horrified, although slightly amused, I suppose, by the tambourine example. It was so powerful and so wrong. It will stay with me as a reminder of the many challenges that we have ahead in dealing with this issue.
I mentioned the issue with the James Paget hospital that my hon. Friend the Member for Waveney is dealing with. He raises the question that many Governments have grappled with—how to get resourcing out of the acute sector and into the community, the area of prevention and helping people with long-term medical conditions. That is very important. I wish the present Government well in seeing whether they can crack that pressing problem, which has been with us for least two decades, to my recollection. My hon. Friend also mentioned what I think is a very good idea—mandatory malnutrition rates and finding out what can be done to ensure that we target that area of deficiency in the NHS.
My hon. Friend the Member for Truro and Falmouth (Sarah Newton), who has secured a Back-Bench debate on the Dilnot report to be held two weeks today, which I am sure as many Members as possible will attend, focused on the complaints process, which I touched on briefly. It is important that the Government learn from the ombudsman’s report, “Listening and Learning”, and implement improvements.
My hon. Friend also mentioned something I have come across in my work with older people in the NHS—language skills. It is completely unacceptable if any carer—any caring member of staff—cannot communicate competently in English with older people, and we should tackle that. She also touched on the rural dimension and on the fact, which was terrible to hear, that her constituents have only one hospital, which inevitably makes people frightened to complain; there is no other choice.
The hon. Member for Wirral South (Alison McGovern) talked movingly about dignity and about older people in society, on which I hope we will hold a debate at some point. The hon. Member for Leicester West (Liz Kendall), whom I congratulate on her new role as shadow Minister, said that the topic could be a debate in its own right, and I am sure that a Member will secure one at some point. I share her belief in the importance of values: most people who work in the NHS have the values that we expect, and as she said, they have to be empowered to make choices and decisions that reflect those values.
The hon. Lady talked about many important areas and enlightened us about the Royal College of Nursing’s staff-to-patient ratios. It is quite wrong that the accepted ratio in a ward with a considerable number of older people is 1:10, whereas a paediatric ward is quite rightly staffed at a ratio of 1:4. The Government should also consider what can be done about concerns regarding the skill mix and the management of resources.
The hon. Lady made some interesting observations about the history of the NHS—how it began in response to cures and to treating people with illnesses that were likely to get better, and how it has not quite kept pace with the number of people who grow to an old age, some of whom need help with care and, perhaps, dying with dignity.
The hon. Lady made a point, on which neither I nor any other Member had focused, about doctors, who provide a huge amount of care in hospitals.
The hon. Member for Bolton West (Julie Hilling) commanded our attention with the moving story of the dreadful time that she and her family had experienced with her mother. I think I can speak for everyone when I say that we wish her mother a continued recovery. It was impossible to determine how the story would end when the hon. Lady was speaking, but it is marvellous that after all the family has been through her mother is on the mend, and we hope that she will recover as much of her former joy of life as possible.
I am grateful for and most encouraged by the Minister’s reply to the debate. He reminded us of the Government’s recent decision to ensure that ageism is not tolerated in the NHS or the Department of Health, which is a good development. He cited many examples of good work and guidance, of which he said there was no shortage, of leadership and management and of spreading good work and guidance into more areas of the delivery of NHS care. I am particularly delighted that he has promised to discuss with the nursing Minister, my hon. Friend the Member for Guildford (Anne Milton), my proposals on nurse training, and how an apprenticeship model should increasingly underpin the degrees nurses take to qualify.
I hope I have covered the important issues that Members have raised today. I thank those who supported my bid for a debate to the Backbench Business Committee and all those who attended this afternoon and made such an important contribution.
Question put and agreed to.