Report (7th Day)
Relevant documents: 18th and 22nd Reports from the Constitution Committee
240: After Clause 207, insert the following new Clause—
“Power to regulate health care support workers in England
(1) The Nursing and Midwifery Order 2001 (S.I. 2002/253) shall be amended to provide that all health care support workers in England shall be regulated in accordance with the terms of that order.
(2) For the purposes of subsection (1), a health care support worker shall be an individual whose work is routinely delegated to them by a registered nurse or midwife or has a qualification in health and social care at level one (or higher) of the Qualifications and Credit Framework, in England.”
My Lords, I rise to speak to Amendment 240, tabled in my name, which relates to the mandatory training and statutory regulation of healthcare support workers. Before so doing, I thank the noble Earl, Lord Howe, and the noble Baroness, Lady Northover, for the time that they have given me in addressing this issue and for their very helpful responses.
The Bill is concerned with reorganising health service structures to improve the quality and safety of care and to improve the patient experience, building on the work of the noble Lord, Lord Darzi, in the last Government. The emphasis throughout the Bill is the role to be taken in the commissioning of services by general practitioners, but little attention has been paid to the other professions. Here I declare my interests as a retired nurse not on the Nursing and Midwifery Council register, a former tutor, manager and chair of the regulatory body for nurses, midwives and health visitors. I am also a lay member of the GMC, a former chairman of an NHS trust and a former trustee of the Kent Community Housing Trust.
I remind the House that nursing and midwifery form the largest individual professions in the NHS, currently with in excess of 600,000 names on the register. Moreover, some 400,000 members of the Royal College of Nursing support this amendment. It is concerned with the safe delivery of care to patients whether they are in hospital, in the community or within the NHS, local authority or independent sectors, along with nursing homes and charities.
I am grateful to all noble Lords who took part in the debates in Committee on the two amendments that I tabled then, the first of which asked the Government to produce guidelines on the ratios of registered to unregistered staff. I withdrew that amendment on the basis that further work would take place examining the research evidence. I am pleased to say that Ministers have taken this seriously and work is now in hand on the matter. I mention this as the ratio of nurses to unregistered staff is important in the points to which I now wish to draw the attention of noble Lords in making the case for healthcare support workers to be regulated against agreed standards and for this to be included in the Bill.
If this amendment is accepted, it would affect healthcare support workers—those who are limited to working under the direction of a registered nurse or midwife giving direct clinical care in hospitals, community settings and care homes. They would have accepted professional boundaries and would be entitled to practise, as set out on a list. There would be control of admission to and removal from the register. Professional standards of practice would be established, ensuring clarity for patients, the public and professionals, and individuals would be held accountable.
In a letter to me, the noble Earl said that the department is “unconvinced” that the regulation of support workers is necessary and that the Government’s policy is to set up a voluntary register. I am hoping to convince the Minister that having healthcare support workers subject to a voluntary register would not work satisfactorily in terms of protecting patients in the delivery of safe care. I pose two brief questions. First, what is the evidence to demonstrate that unsafe care is currently being delivered by healthcare support workers and the reasons for this? Secondly, is there evidence that will satisfy patients, the public and registered practitioners that the proposed voluntary register will ensure the safe delivery of care?
While a very large number of healthcare support workers deliver excellent care, most of them having received some basic training under adequate supervision and having gained experience, there is evidence that things can and do go dreadfully wrong, particularly where there is no appropriate training and poor supervision. Healthcare support workers are themselves calling for mandatory training and regulation.
We have only to refer to the most recent inquiries demonstrating unsatisfactory levels of care in Mid Staffordshire NHS Foundation Trust. The first report was very critical of healthcare support workers and the change in the staffing ratio of registered nurses to support workers. The second public inquiry is reporting on the confusion about supervision—not knowing who was in charge of care delivery. At Winterbourne View, a hospital delivering care to those with learning difficulties, charges were brought against support workers and guilty pleas have been made. The report published by the Local Government Ombudsman cited 10 instances of unacceptable care for the elderly. Moreover, prior to this there were inquiries at Maidstone and Tunbridge Wells NHS Trust and at Stoke Mandeville Hospital. While the failures in delivery of care were not due solely to the poor performance of healthcare support workers, that was found to be very largely a contributory cause. Failure in delivery of safe service care was due in the main to there being insufficient registered nurses to supervise the healthcare support workers and a lack of a set of standards for care training.
A survey of 2,500 support workers carried out by the Royal College of Nursing between the Committee and Report stages of this Bill demonstrated that tasks currently being undertaken by healthcare support workers call into question the safety of patient care. The list totals 56 examples, but I will illustrate just a few. Healthcare support workers were left in charge of wards and nursing homes, administration of drugs, including insulin and controlled drugs, the removal of wound drains and central lines, bladder scanning and washouts, catheterisations, especially in very ill patients, assessing patients pre-operatively and pre-chemotherapy treatment, changing tracheotomy tubes, inserting nasogastric tubes, giving feeds through those tubes, and suturing and plastering. These are just a few.
As recently as last Friday, I was chairing a national conference and was approached by a very senior nurse who told me of a family member, a young person of 17, who had applied for a job as a healthcare support worker. She received two days’ training. On the first day on the ward, she was allocated to do a bed bath. She was accompanied by another healthcare support worker to supervise her. She washed the patient’s face and hands and proceeded to complete the bath, but was told by the other healthcare assistant, “I only do hands and face here. We don’t bother to do anything else”. When questioned about the patient’s back and pressure areas, she was again told, “We do not do that here”. Very many of our workers are in that situation, both in the community and in hospitals.
A House of Commons Health Select Committee report says about the future of regulation:
“The Committee endorses mandatory statutory regulation of healthcare assistants and support workers and we believe that this is the only approach which maximises public protection. The Committee notes that the Government intends to give powers to the relevant regulators to establish voluntary registers for non-regulated professionals and workers, but would urge it to see healthcare assistants, support workers and assistant practitioners as exceptions to this approach who should be subject to mandatory statutory regulation. However, the NMC”—
that is, the Nursing and Midwifery Council—
“needs to make significant improvements in the conduct of its existing core functions (such as in how it manages fitness to practise cases) before powers to register these groups are handed to it”.
This is now work in progress.
It is not possible to provide evidence that a voluntary register would be satisfactory, but I can show why a voluntary register for healthcare support workers would not solve the problems that I have illustrated. A healthcare support worker works under the direction of a registered nurse or midwife, who delegates the task having judged the competency, knowledge and experience of that support worker. The list of tasks currently being undertaken is such that it is doubtful that adequate training has been given, and most fall outwith the tasks that a support worker should be expected to carry out.
As already stated, there is not yet a set of standards which would form an agreed list of tasks that healthcare support workers could work to. The Government have asked Skills for Health and Skills for Care to carry out this work. Are registered practitioners and university lecturers involved in this programme of development? I ask this question because I know that the former chief executive of the Nursing and Midwifery Council was asked by the Minister and the Department of Health to become a board member of Skills for Health and Skills for Care and to make the appropriate contributions for the regulating body. There is a need for his professional input in the interests of safety of patient care, not just courses teaching skills without the appropriate level of knowledge to accompany those skills—that is, the ability to recognise a change that indicates that further help is needed. I gave in Committee the example of the taking of blood pressure and the consequences of not knowing what a change in the reading might mean.
There is considerable scepticism over the possible introduction of a voluntary register for this group of workers, mainly because those who most need to register are the least likely to do so, especially with so many unemployed people taking any possible job on offer without proper scrutiny. A voluntary register provides no mechanism to stop people working—that is, a fitness-to-practise investigation. Plurality of employers and greater employee mobility could present problems for a voluntary register. It would be difficult to check where people moved to and to keep tabs on their whereabouts. There would be no single register and no single point of contact. There is already confusion for public and patients, and a voluntary register would add to that. There needs to be consistency. There are no current enforceable standards—I accept that preparations are being made to ensure that standards are set. Anyone could set up a voluntary register. Some could be kitemarked and some not. There are issues around how a voluntary register would work alongside the Independent Safeguarding Authority. Would it be fit for purpose in determining fitness to practise if presented with a person considered unfit for work?
Surely healthcare support workers deserve more than this. They are often subject to misuse and abuse. But we are where we are. Registered nurses are frequently placed in an impossible position because the numbers available in relation to the number of support workers to be supervised under their delegation make it difficult to ensure that safe practice is being delivered. That is especially so now with the cuts in registered nurses and midwives in the current economic situation and the Nicholson challenge of the £20 billion savings target.
Patients and the public need to be assured that they are the recipients of safe care delivered by appropriately qualified staff. The confusion that currently exists about who is who in the team causes anxiety to patients and relatives. Patients and relatives know when a doctor comes to see them that he or she is qualified and registered with the GMC to do the job. At the present time, they cannot be sure whether they are being treated by a registered nurse or a healthcare support worker unless the demarcation is easily identifiable to a patient, member of the family or the public.
The situation that we are faced with is a very serious one and urgent action needs to be taken. There is no short-cut remedy. What is needed is an ordered strategy that takes evidence on the requirements of safety, high-quality care and good patient experience in hospital, the community or the care home, providing holistic care and at the same time cost-effective results. The work that is being examined on the evidence relating to the proportion of registered nurses to support workers shows that care must take the lead. The professions of nursing and midwifery must be allowed to take a lead and assist in determining and demonstrating their worth as professionals, to regain the confidence of patients, the public and the Government, and in turn to determine the level of support workers that they need to deliver this high-quality, holistic care.
That can be done by involving the recently created Nursing and Care Quality Forum, created by the Prime Minister, involving the Royal College of Nursing, the Royal College of Midwives and other professional bodies and unions. Of course there are two new chief nursing sisters—one to be appointed this week to the national Commissioning Board and one already appointed as Chief Nursing Officer of public health—who will help to lead in this.
I have set out why I do not think that a voluntary register is an answer. I am looking for a commitment that the mandatory training for healthcare support workers will have a strong input from the profession in developing and validating the competencies and outcomes required for healthcare support workers. I also want a commitment to review that education and training to establish the benefits that it has had for patient safety. I beg to move.
My Lords, I wonder if I may be indulged again by the House by speaking from an unusual position. I speak against a background—dare I say to my noble friends on the Front Bench—that I have been suitably chastened on the way into the House by being told that yesterday was the first day on which Tory rebels outnumbered Liberal Democrat rebels. There was only one rebel: it was me. Here I stand trembling, yet again.
The spirit in which I approach this is slightly interrogative. I was not able to hear the earlier debate that the noble Baroness triggered, but I am puzzled about the Government’s position on this. I want to ask a few questions. I have no problem at all with tasks being delegated down to the appropriate level. I became Minister of Health 25 years ago, on the day that my noble friend Lady Cumberlege’s report into nurse prescribing was published. Ever since, I have thought that there were a lot of things being done on one level that could sensibly be done at another. I have no problem with the general principle of using healthcare support workers for things that might have been done by others in the past.
However, when it comes to things that are clinical, it is important that people should be trained and properly authorised and registered. That is the key point. Anyone who has been in hospital, as I have on a number of occasions in the past two or three years, will recognise that it is not always easy to work out who does what. I have no complaints about any of the people who looked after me, but it is quite clear that they are at different levels and that one would want to be confident that they all knew what they were doing. The noble Baroness referred to the importance of some of the work that healthcare workers do and we all know that one mistake in medication could have fatal consequences, for example. She referred to the various reports, which I will not rehearse, and she made a number of points that we ought at least to listen to with care.
However, as I said to the noble Baroness in a private discussion, I was a bit sceptical about this because the numbers are potentially huge and we do not want another example of a body being asked to take on more than it can do in too short a time. To some extent, I think that she has sought to meet that in her amendment by narrowing the definition of healthcare support workers to those who are in the clinical area, if I might use that shorthand. That is welcome. But I still think that there may be some problem with the scale of the task if it is imposed at one go. The noble Baroness is aware of my worries about that.
I am also less convinced that a voluntary register could not have a significant effect, with some provisos. First, we cannot have competing voluntary registers with people free to choose the one that they think is easiest. If there is to be a voluntary register, it must be officially sanctioned—I would be grateful for comments on that. If you have one, it might have a significant effect. It would be a brave health trust, once the system was established, that took on healthcare workers who were not registered because of the risk that would arise if something went wrong and the criticism that would ensue. So it might have an effect and I think that we should take account of that.
Even if the Government want a voluntary register and think that it could work, there is a parallel in the field of ombudsmen, which I know something about. That would be to have in the Bill a reserve power to take compulsory registration powers if that proves to be necessary. I am not sure whether that is there or not, but a fallback position might be to have the power to act if the Government’s preferred solution does not work and I would personally press that as a possibility to the Minister.
My Lords, first, I apologise for missing the first five minutes of the noble Baroness, Lady Emerson, moving the amendment. With the House’s permission, I shall briefly speak to the issues that she raised, to which I have referred in the House on many occasions, as many noble Lords and certainly the Minister will be aware.
I understand the arguments that have been made by my noble friend, but healthcare assistants—and they are mostly in clinical areas—have a strong desire to be recognised and accredited for the work that they do. They take a pride in what they do, as the noble Baroness, Lady Emerton, said, but patients do not understand what they do and therefore cannot have the discussion with them that says, “You are qualified, so I have confidence in you”.
I have had this discussion with the Minister on a number of occasions, and I am not sure why there is hesitancy in this area. I do not think there is an issue for trusts in being able to get healthcare workers who are qualified. We have a sector skills council for health, most of whose work is encouraging healthcare assistants and other people who work in hospitals to reach levels 1 and 2, so there is an equivalent provider out there that can do that, working with the hospitals.
The important thing is that the patient understands exactly what the healthcare worker does. The amendment of the noble Baroness, Lady Emerton, describes a healthcare support worker as an individual whose work is “routinely delegated to them”. That is crucial. It is not someone who does something off their own bat. My hospital employs many hundreds of healthcare workers, most of whom do a very good job. It is very important that the noble Earl knows that they are very conscientious when working with other practitioners, clinical or otherwise, who do not do what they are supposed to do. We have many healthcare workers who check that consultants’ arms are bare to the elbow. They are very conscientious and they want recognition that they are people who care about patients. They want to know that the value that they bring is recognised. It is no threat to the health service; speaking as a provider chair, I can say that it is a total advantage.
My Lords, we are once more discussing the important matter of the power to regulate healthcare support workers in England. I am pleased to have added my name to the amendment. I spoke about this at Second Reading and in Committee. I agree with the Royal College of Nursing that mandatory regulation and registration of these support workers is important in order to safeguard patients’ safety and to ensure standardised training so that there is a skilled and suitable workforce.
I have yet to meet anyone who understands the situation who disagrees about this, except some members of the Government. Nurses who have been struck off their register can then work as care assistants—again, putting patients at risk. The Government are considering a voluntary register, but this will not cover the undesirable people who get jobs as care assistants because they cannot get employment elsewhere. Clinical physiologists have found that self-regulation, which they have had since 2001, is not as effective as statutory regulation. Should we not learn from this?
We know of the tragic cases at the Mid Staffordshire NHS Foundation Trust, where the deaths of hundreds of patients were associated with bad care. It makes one wonder how Mid Staffs was approved for foundation status. We also know of the horrific bullying by care assistants at Winterbourne View care home at Bristol. Since Committee, we have heard of Malcolm Cramp, who was convicted of seven counts of ill treatment and sent to prison for abusing dementia patients at Brockshill Woodlands, a care home in Leicestershire. In another case, Sean Abbott, a caseworker, was jailed for a year for assaulting vulnerable residents at St Michael’s View care home in South Shields. Daphne Joseph, another person at that home, was given a nine-month suspended sentence when she admitted the ill treatment and neglect of a patient, who died. The judge at Newcastle said that she had not had enough training. He also said that she was operating,
“in a regime which was inadequate and not fit for purpose and in which there were too many patients, not enough planning, and too few staff, let alone trained staff”.
This concerning situation is happening up and down the country. Is it not time that better safeguards for patient safety were put in place? Statutory regulation and the registration of healthcare workers could help. Many of them are now undertaking procedures that only doctors and nurses did but they have little training to do it.
My name is attached to this amendment, which I believe is an extremely important one. I find myself in the somewhat unusual—indeed, unique—position of, for the first time, not being able to agree with the noble Lord, Lord Newton. We have had many debates in this Chamber in which the standards of care in our hospitals and nursing homes have been examined and, in too many places, found wanting. We have had many other reports showing the same thing. Many institutions and many care workers are outstanding but, as we know, there are too many places where patients are neglected and their basic needs not addressed.
Of course, all these failures cannot be put at the door of healthcare support workers. Where they occur, these failures are systemic and go right across the hospitals and homes. The employers, doctors, nurses and everyone in the institution should bear responsibility. However, all too often it is at the level of the healthcare support worker—who provides the basic care of feeding, washing, toileting and a host of other responsibilities and is often in closest contact with the patient—that we hear complaints from patients and their families. Healthcare support workers are at the end of the line and are too often left to themselves.
I fear that when we lost our SENs—our state-enrolled nurses, who did not need a university degree—in 2000, we lost a group of professionals who were trained and educated to do their job. If we are to regain the sense of professionalism and pride that my noble friend talked about that full registration would bring to a cohort of well trained and regulated young men and women, then we must move to full and proper registration. I do not believe that a voluntary register gives that degree of control. It certainly does not give sufficient recognition to the importance of the job. I hope that the Minister will agree.
My Lords, I apologise to the House for not being here at the start of this amendment. Unfortunately, I had to seek the help of the health service this morning for a touch of bronchitis. I apologise particularly to the noble Baroness, Lady Emerton, for not being here on time.
I strongly support the amendment. I have spoken on this matter on each occasion that the call for statutory regulation has been debated in this Bill. I also referred to this issue in the debate on front-line nursing which we held last December.
The Government argue that voluntary registration is sufficient unto the day. I beg to differ strongly. As a nurse, I cannot agree that the present state of affairs should continue, and I do not think that I am a lone voice. The health committee in another place, the Nursing and Midwifery Council and all the staff organisations representing healthcare assistants all support statutory regulation.
History has a habit of repeating itself—wheels turn full circle. In the 1930s, financial pressures brought about huge increases in the numbers of support workers, or assistant nurses, as they were called. There was no provision then for regulation. It took the work of two committees—the Athlone Committee in 1937 and the Horder Committee in the early years of World War II —to lead to legislation which allowed for registered and regulated status for assistant nurses. We had state-enrolled assistant nurses as a consequence, and I think that it was in the early 1960s that the word “assistant” was removed from the title.
By the 1980s, the role of nurses on the first and second parts of the register was blurred. As a consequence, and as part of the move away from hospital-based training into higher education, the enrolled nurse training for first-level nurses was discontinued. It was always a mistake to leave that vacuum when the enrolled nurse training ended—a matter referred to by my noble friend Lord Turnberg.
The outcome is entirely predictable. That wheel has, indeed, turned full circle. We have had, again, huge increases in support staff; we have, again, financial stringency; and, as in the 1930s, there are now campaigns for proper regulation and training for those who assist nurses. However, the roles have been blurred this time not between the enrolled nurse and the registered nurse but between the healthcare assistant and the registered nurse. That is the very issue that led to the ending of enrolled nurse training, but this time there is no fall-back—there is no fail-safe for the patient—because there is no standardised training; there is no legal obligation in the Bill to require standardised quality training; and there is no obligation for registration, regulation, accountability and, not least, a code of conduct for support staff. The amendment in the name of the noble Baroness, Lady Emerton, will do much to resolve that issue. Most importantly, it is about patient safety. The amendment is specific—it is not about all support workers working in the hospital service or care homes; it is about those staff to whom are delegated what are, by any standards, nursing duties of registered nurses. It is not good enough for the Government to keep saying that voluntary registration is sufficient and that everything else is a matter for employers.
That is the present situation and it is far from satisfactory. I suggest that it will get worse in the future. We all know that the ratios between nurses and healthcare support workers are often worse than the generally accepted 60:40. The financial squeeze will certainly mean further changes—and not for the better. Voluntary registration does not work. For a long time, for example, clinical physiologists have been trying to make the case to the Government that voluntary registration has failed, and the coalition Government have turned their face. The leaving-it-to-the-employer approach will leave the patient at risk, and neither the registered nurse nor the healthcare support worker is protected in these situations if something goes wrong. Increasingly, the employer will be exposed as well, as there may well be more cases such as that of Mid Staffordshire as a consequence of financial pressures and getting skill mixes wrong—not least when these decisions are made by human resources people with little or no proper nursing input.
In my submission, the patients are not always clear about who is providing care for them. My recent six months as a patient in two teaching hospitals confirmed that—virtually everyone in a uniform was a nurse to most patients. That is not surprising. Healthcare assistants routinely carry out observation rounds; they carry out clinical procedures such as cannulation and catheterisation; they give injections; and they undertake venapuncture to take blood. That is just to name some of the procedures that they might carry out. Patients would be very surprised if they were told that the staff carrying out these clinical procedures were neither regulated nor registered.
Regulation and standardised quality of training does not, in itself, guarantee that matters will not sometimes go wrong. That can—and does—happen in all regulated professions. However, statutory regulation and registration is the best way forward to give better surety to patient safety. I strongly support these amendments.
My Lords, I support the amendment of the noble Baroness, Lady Emerton, from two perspectives. One is as the chief executive of Diabetes UK, where we increasingly hear stories from patients about the care that they receive in hospitals. One in 15 of all patients in hospitals at the moment has diabetes. They may not be there as a result of their diabetes but they have it—it is, of course, a serious condition. There is strong evidence that poor care in hospitals exacerbates that condition rather than improves it. I shall just mention two issues: people lose control of their own insulin and glucose management and they develop pressure problems—particularly foot and leg problems, which can dramatically escalate and lead to amputation.
Patients increasingly tell us that one of the major problems that they face in receiving care as an in-patient is that readings, checks and procedures are undertaken by healthcare support workers who are insufficiently trained and knowledgeable to alert qualified staff to take action. Just yesterday, the All-Party Parliamentary Group on Diabetes heard the distressing story of a gentleman who had been admitted to hospital and who went into a hypo through insufficient management of his glucose levels as he lay in a hospital bed. The healthcare support worker said, “I thought you were a bit strange when I gave you your lunch”. If people with diabetes “go a bit strange”, any qualified nurse will know instinctively that this is serious and needs to be dealt with. It is unforgivable that patients in a healthcare establishment have worse control over their diabetes than when they are in their own homes. I am not laying that at the feet of healthcare support workers entirely but, increasingly, the care given to people in beds, day in and day out, is given by people who need to be accredited and qualified.
The second perspective from which I want to speak is as the ill-fated chairman of the Care Quality Commission who set up the regulator for health and social care. I confess that one of my great regrets, when I resigned from that post, was not to be able to take forward work that I saw as absolutely vital. It had become abundantly clear to me, from the regulatory work in healthcare, that the key to quality was very dependent on the quality of nursing care. It is absolutely central to quality as a whole for people in healthcare. What has also become clear to me—and the evidence is borne out in many cases of poor care—is that it is not published standards or agreed levels of care that are important but the knowledge, education and skill of the nurses and healthcare support workers who are providing that care. It is about how they feel about the job and about their commitment to the job—not just seeing it as another job but seeing that improving things for patients is at the centre of what they do.
Had I stayed as chairman of the Care Quality Commission, I was intending—and I had already begun discussions with the Royal College of Nursing and others —to mount a major campaign to ensure that the nursing process, and with it, at its heart, the healthcare support worker, was improved and that formal registration and regulation of healthcare support workers was introduced. The Minister may well say that these improvements can be tackled through a voluntary register but, from my experience, I do not believe that this is the case. This is so important that a formal statutory register is absolutely required.
My Lords, I support the amendment. I note that one of the reasons given for not considering statutory regulation for this group is that there is a very high turnover of staff in this grade. This seems to me to be a symptom of an unsatisfactory situation and perhaps points to the poor job satisfaction and lack of prospects for healthcare workers. My noble friend has pointed to the problems with skill mix. I think that she was really talking about skill mix across the whole range of mental and physical healthcare settings and not just physical healthcare. Within that, she would have included people with learning disabilities.
It seems to me that there must be some minimum requirements for training and supervision. I know that the Government suggest that it is the responsibility of the employer, and perhaps also of the commissioner, to ensure that the service which is provided reaches minimum standards. Perhaps that requires that, in order for commissioners to contract with an employer, a service has to have been appropriately accredited. A service which has been accredited has of course been accredited for the whole service, not just for the work of individual staff, who are subject to their own regulatory authority.
This morning, I revisited the Royal College of Psychiatrists’ accreditation standards for adult in-patient wards for people with learning disabilities—I should remind noble Lords that I am a past president of the Royal College of Psychiatrists and a psychiatrist myself. The college’s general standards very helpfully include attending to recruitment and retention of staff, training, supervision, management of complaints and so on. It is helpful to think about the relationship between the necessary accreditation of services and the need to attend to the training and aspirations of all those staff who work in such services: retention and job satisfaction are key to this.
My Lords, I join with others in paying tribute to the noble Baroness, Lady Emerton, for her tenacity and commitment in keeping the issue of healthcare assistants before your Lordships’ House. She may not be my noble friend in the political sense, but she has been my friend in the professional sense for many years.
I am sorry, therefore, to disagree with her on this particular issue. Indeed, it seems that I am a lone voice disagreeing with her. I certainly want to emphasise that I do not disagree about the problem with regard to healthcare assistants which has been so thoroughly and persuasively set out by her and other noble Lords. But the Council for Healthcare Regulatory Excellence, the organisation which I chair, disagrees with her, as she knows, about statutory regulation being the solution to these problems. The CHRE has had the opportunity of speaking to many of your Lordships in two seminars organised by the Minister, so I do not need to take up time here repeating the arguments. I will say only that mechanisms already exist to deal with the difficulties which your Lordships have set out. These include ensuring that those supervising healthcare assistants take their supervisory responsibilities seriously. The Nursing and Midwifery Council is providing strong direction on this with its codes. Employers are required to ensure safe systems of work, which include giving support to healthcare professionals in delegating and supervising effectively. There is also the vetting and barring scheme, whose aim is to prevent unsuitable people from entering or remaining in the workforce.
Add to this the expense and relative slowness of statutory regulation and it seems to add up to a case showing that the increased public protection that we are all seeking can be achieved by applying existing mechanisms more firmly. We should consider other ways of making this large group of workers, low paid as they are and with a 30 per cent turnover, as we have been reminded every year, feel more acknowledged and valued. There may well be a role for a professional association with a voluntary register, but principally we must use existing processes effectively before we embark on statutory regulation.
With regard to voluntary registers, which have been mentioned so much this morning, or accredited registers, as proposed by the Bill, much work has already been done by the CHRE. We are using the term “assured registration” to distinguish it from the old notion of voluntary registers and to describe the process of organisations assuring the individuals on their register and then the CHRE accrediting the organisations and their registers, thus creating accredited registers. I remind your Lordships that the whole purpose of such a scheme is to enhance consumer protection. The standards to be met by organisations which hold accredited voluntary registers will include standards of competence, education and training, registration of complaints and information provision. I certainly do not want to argue that this is the same as statutory regulation, but for many professions it offers further safeguards for patients and public, and that is what we are all seeking.
My Lords, my noble friend Lady Emerton moves a very important amendment that comes to the very heart of this Bill. The purpose of this Health and Social Care Bill is to ensure ultimately that quality is driven throughout the healthcare system and that standards are driven to the very highest levels. It seems counterintuitive that such an important group of healthcare professionals as healthcare support workers is not subject to any mandatory training or mandatory continuing professional development or, indeed, any form of statutory regulation. I suspect that many of our fellow citizens would find that a very peculiar situation, which they would not automatically recognise, when going into the hospital environment.
I would like to ask the Minister two questions, specifically with regard to proposals for ensuring strong voluntary registration of this particular group and members of other disciplines who are responsible for the provision of healthcare. The first relates to the role that the Secretary of State might play with regard to standing rules and providing guidance to commissioning groups on the action they should take and the requirements they should make of qualified providers. Will it be the case that commissioners will be in a position to demand of a qualified provider that all of their healthcare staff, be it doctors, nurses, or other healthcare professionals, are members of some form of registered regulatory scheme, be it a regulatory scheme for certain healthcare professionals or voluntary schemes for others? Will it therefore be possible for clinical commissioning groups in the future to refuse to commission from a potential qualified provider if that provider was unable to demonstrate that all the staff it employed were registered appropriately?
My second concern relates to a plurality of registers for a single discipline of healthcare worker. That seems counterintuitive: surely, if there is going to be a voluntary register for healthcare support workers, there should be a single register, not multiple ones, because multiple registers would provide less confidence to the general public. The general public should know that there is a single regulatory body and that that body has responsibilities with regard to setting certain standards, with regard to ensuring that there is appropriate training and with regard to the possibility of receiving complaints and disbarring individuals from working in that professional area.
My Lords, I agree with those noble Lords who have said that this is a critical amendment. I do not understand how more than one register will ensure a uniform standard across the whole of the NHS. There is a real problem at the moment with healthcare assistants being used as substitutes, rather than having “delegated” tasks, as in the wording of this amendment.
I am concerned about relying overly on the employers themselves. We have seen in the nursing home sector that this has failed. Where there has been substandard care, nursing homes have not got rid of those staff about whom they have had questions and those who have been commissioning services from those areas have not been able even to close down nursing homes because they often have not known where else they could move the residents of that area. In the mainstream hospital sector, it is down to an individual nurse to decide what she delegates to a healthcare assistant. The beauty of having a statutory register is that there will be clear expectations of what healthcare assistants can and cannot do and the level to which they should be trained, with clarity of roles and values, which I believe will also increase their own self esteem, and their own sense of occasional involvement in their role in clinical care. It has been suggested that it would be in the interests of unions to have such a statutory register. I fear that there has even been confusion in the minds of some people between the role of a trade union and the role of a regulatory body. It will be very important that a register is completely separate to any type of union activity. When the Minister comes to answer, I would be grateful if he could explain how the standards to be set by a voluntary registration process will be overseen and monitored, and what levers the Government would have to improve and extend the criteria required by a voluntary register of those who are registered on it, in order to increase standards.
My Lords, I have added my name to this amendment, which has been moved by my noble friend Lady Emerton. The case for statutory registration, which I strongly support, has been made in a tempered way by my noble friend. Perhaps I may first try to address the lone voice of the noble Baroness, Lady Pitkeathley, because she must be concerned about being the lone voice. She said that we should allow the current regulations and procedures to take effect before making a decision. Currently, we have no procedures. There are proposals to put procedures in place both for training and possibly for registration, but we have nothing apart from that. I went to the seminars, although with respect I have to say that they were not very helpful. There are two points I want to make as a result.
When asked about the question of voluntary versus statutory registration, the response of the officers of the Council for Healthcare Regulatory Excellence—I wrote it down at the time—was that it is based on the “likely risks”; that is, if the risk is high there must be statutory registration, but if the risk is low it could be voluntary registration. Ample evidence has been provided by two former nurses in this House, my noble friend Lady Emerton and the noble Lord, Lord MacKenzie of Culkein, to show that we are talking about a high-risk situation. The second comment was that it was not within the power of the CHRE to decide whether registration should be statutory or voluntary. Of course it can take a view, and if that view is based on evidence, it would be taken seriously. However, the evidence presented by all the speakers in today’s debate is quite contrary. On both of those counts, the council’s arguments are weakened. I shall leave it at that.
I accept that we are talking about a huge workforce, one of 450,000 or perhaps more. It could be higher than that if healthcare support workers are employed in the community, in care homes and institutions for mental illness and care. So while I welcome the Government’s plans to introduce new minimum standards of training for healthcare support workers, they do not go far enough to ensure professional competence. While there would be an expectation that employers will both provide training and support a code of conduct, there will be no legal obligation to do so. I may be wrong and no doubt I will be corrected, but I believe that a mandatory, standardised approach to both training and regulation is essential in order to maximise public protection.
The noble Lord, Lord MacKenzie of Culkein, referred to the long list of activities in which healthcare support workers now engage. It is quite different from what I was used to. Nursing auxiliaries would undertake essential nursing care and sometimes domestic duties. Those support roles have now been extended, to the point of what the noble Lord, Lord MacKenzie, described as cannulation and catheterisation. As well as the issues of public safety and protection referred to by my noble friend Lady Emerton, there is a lack of clarification on areas of responsibility, delegation and accountability. Evidence shows that the responsibilities and tasks given to healthcare support workers vary across the country, and even within the same setting—for example, between different wards in the same hospital. In addition, the relationship between individual registered nurses and the healthcare support workers working alongside them can sometimes determine what duties they are asked to perform rather than recognition of their education, training, experience and competence. This variation across and within settings has led to a lack of clarity about roles and responsibilities.
Regulation and standardised training would give healthcare support workers much more clearly defined roles, and I agree with the Government’s intentions on this. This would help to ensure that support workers are only asked to perform tasks that are suitable for their competencies and would provide them with a code of conduct. They would be protected in circumstances where they are asked to undertake tasks for which they are not competent or about which they are unsure. I support that and I am glad that the Government, together with the professional organisations, are beginning to set out their intentions. No doubt the Minister will comment further on that.
I turn now to the issue of voluntary versus statutory registration. I believe that voluntary registration over the long term will lead to fundamental weaknesses. Those individuals and employers who most need to be regulated may not sign up to a voluntary register or could abuse the flexibility of its voluntary status. Through the proposed reforms in this Bill, an increased number of service providers is expected, and that might confuse the situation even more. There will be greater mobility in the workforce which could create the possibility for professionals to avoid reprimand following poor conduct by seeking employment with a different employer. Over the long term, voluntary registration will allow any organisation, employer, representative body or third party to establish a register. Some of those registers may well be successful and could, for example, achieve a “kitemark” standard. The noble Baroness, Lady Pitkeathley, referred to “assured registration”, but I do not know what that is. Is it a halfway house to statutory registration or is it half way down the road to inadequate voluntary registration? I presume that it would be a halfway house to statutory registration, which is a good idea.
There would also be the possibility of an individual gaining access to another voluntary register following their expulsion from one. Without national standards, it is not clear what the registers will take into account when accrediting an individual. These issues engender a lack of consistency. One single statutory register with clear terms of reference would not present such a problem. A mandatory register would also provide a single point of contact for potential employers when checking the employability of an individual, and differing levels and standards of registers would not exist.
I recognise, as did my noble friend Lady Emerton, that we are talking about the registration of a large workforce, and that prior to doing so training has to be provided for that large workforce. We need to consider the direction of travel: where we are, where we want to be and how we are going to achieve that. It is an important issue and I look forward to the Minister’s comments.
My Lords, I shall be extremely brief in supporting what my noble friend Lord Patel has said. I have listened with care to the debate. This is a huge workforce in which at the present time the standards of professional behaviour and competence are immensely variable, where the standard of education among the individuals performing these tasks is also extremely variable, and where it is clear that an improvement in standards not only of care but of responsibility and training is absolutely vital. The question we have to ask is how this can best be achieved.
I found the arguments of the noble Baroness, Lady Pitkeathley, very persuasive, and of course I understand the stance she is taking as the chairman of the Council for Healthcare Regulatory Excellence. It is soon to have its name changed, but a rose by any other name will smell as sweet. It will have responsibility for accrediting the voluntary registration of a large number of individuals working in the National Health Service. She is persuaded that a voluntary register for these healthcare support workers would be adequate and satisfactory. However, as my noble friend Lord Patel has asked, what will prevent those individuals who are responsible for or who own care homes taking on board and employing people who are not voluntarily registered? This is a crucial issue, as indeed is the point —it has not been effectively clarified to my satisfaction—about what sanctions may be applied to people who do not fulfil all the eligibility criteria that are to be established for that voluntary register. Having said that the noble Baroness, Lady Pitkeathley, was very persuasive, I am afraid that I find my noble friend Lady Emerton infinitely more persuasive.
For that reason, I have not the slightest doubt that I strongly support the amendment. It is not suggesting that a new register and national body for care assistants or a support workers’ national council needs to be established. The virtue of the amendment is that individual healthcare support workers in England would be regulated in accordance with the terms of the Nursing and Midwifery Order 2001, which is already a statutory order. It seems to be a neat solution to an extremely difficult problem. For that reason, I strongly support the amendment.
My Lords, I had not intended to speak in this debate, but I want to strike what might be a slightly discordant note at this point in the proceedings. I have a question for the noble Baroness, Lady Emerton, and the noble Earl in relation to clarification.
I will speak later in relation to social workers and that bit of social care which we seem to have forgotten. What has concerned me most in this debate is the total confusion between social care workers and healthcare workers. What really concerns me about the amendment is that it appears to be the health professional who must give instruction to those working in a variety of establishments. I declare an interest as someone who is responsible as a trustee for a large number of elderly and disability care homes. In some of those places, someone qualified in social care and not healthcare is in charge of the establishment. They are therefore responsible for ensuring that the programmes of care are designated with some healthcare professionals, because in nursing homes you need both working together.
I want to be absolutely sure that we do not arrange more confusion, which we will be discussing later today in relation to social care, and undermine even further those people who are looking after the real day-to-day care, not the medical health needs. You need people looking after medical health needs in these establishments, but you also need to worry about stimulation, relatives visiting, the psychological approach to the people in the home, how they will get to hospital and helping the hospital to understand what people with disabilities are saying. All of those things are crucial and need equal registration and care.
I am attracted to the voluntary register because it means that we can look at all these people who are working in the field who have their own professional positions but are different. I would like some clarification and for the House to understand that there is not just a medical group of people caring but a whole tranche of people out there in establishments and in the community looking after those needs, which I am sure noble Lords, if they were in that position, would also want to have looked after.
My Lords, this has been a good debate and I, too, congratulate the noble Baroness, Lady Emerton, on her initiative in bringing forward her amendment. I should remind the House that I chair an NHS foundation trust and, like my noble friend Lady Wall, we employ many hundreds of healthcare support workers. I agree with everything my noble friend said.
The noble Baroness, Lady Howarth, raised an important point. We are coming on to the issue of social care regulation and the House will know that I am very concerned about the transfer of social care regulation to what is essentially a health body. The noble Baroness, Lady Emerton, will want to respond, but it seems to me that what she has tried to do is to allow the House to have a specific debate on healthcare support workers. The amendment is very much a statement of principle and we will come on to social care workers in a later debate.
At heart, this debate is about standards of care in the NHS and the independent sector. We should start by acknowledging the huge advance that the nursing profession has made in the past 20 years. The noble Lord, Lord Newton, is no longer in his place, but I pay tribute to him and the noble Baroness, Lady Cumberlege, for the work that they did to enhance the role of nurses with nurse prescribing. We know that they have taken on much greater responsibility since they became, essentially, a graduate profession. The problem we have is that at the same time there has been mounting concern that basic standards of care have been lost sight of. The noble Baroness, Lady Emerton, referred to the first Francis report into Mid Staffordshire. It illustrated concerns about poor basic nursing care, denials of dignity, issues around nutrition and hydration and evidence of unacceptable standards of care. These concern support workers as well as qualified nurses.
There are big questions about nurse training and qualifications. I, for one, believe that there is a problem with universities and the emphasis that they give to academic and research-based training as opposed to practical training. These issues have still not been resolved satisfactorily. But there are also real issues about healthcare support workers and, as my noble friend Lord Turnberg said, the argument for statutory regulation has become quite persuasive. We have 200,000 healthcare support workers, give or take a few thousand. Most of them do a great job, but there are real concerns about the quality of work that is done by a few. As the noble Lord, Lord Patel, said, we have had the benefit of two seminars in the past week or two, which the noble Earl, Lord Howe, kindly arranged. Yesterday, we were told that it was all down to a risk-based assessment, but the people doing the basic care are these healthcare support workers. There is a real issue of risk.
The department has put forward a fivefold argument in favour of a voluntary approach. First, statutory regulation of nurses has not prevented problems. Secondly, the statutory regulation of healthcare support workers is not proportionate. The department refers to the rapid turnover of support staff. Thirdly, it is really a problem of contracting, poor management and poor supervision of healthcare support workers by professional nurses. Fourthly, the Council for Healthcare Regulatory Excellence, as we heard from my noble friend, will accredit voluntary registers. Fifthly, perhaps the noble Earl will offer some kind of review after a period of time. I will take those one by one.
I fully accept that the statutory regulation of nurses has not prevented every single problem that has arisen in the health service, but that is surely because there are some wider issues to do with training, to which I have already referred. But my goodness me, statutory regulation has none the less provided tremendous safeguards for patients over many years. On the question of proportionality, I respectfully disagree. The fact is that healthcare support workers seem to be taking on more and more responsibility up and down the country. The noble Earl will know that the efficiency saving challenge for the NHS is a tough one. There are some indications that this is squeezing nurse staffing ratios. Inevitably, if that happens, more responsibility will be placed on healthcare assistants. On proportionality, if the argument is that we do not need a statutory register because we can have all these voluntary registers, I would turn that around. If in fact the noble Earl is promising us a voluntary approach that will cover all healthcare support workers at least in the NHS, why on earth not have a statutory register? If you are going to go to all the effort of setting up the healthcare regulatory body, chaired by my noble friend, and of having a number of different voluntary registers— I presume that they will have sanctions because there will be no point in having them unless there are sanctions—what on earth is the point of stopping there, because all the work will have been done? I suspect that we will find that the impact of the voluntary approach is patchy. That is the big problem.
Let us take the issue of contracting, on which the noble Lord, Lord Kakkar, asked some very pertinent questions. Can we be assured that commissioners will insist that all providers ensure that their healthcare support workers are on the voluntary register? That is a very good point. But can the Minister go on to say that he will insist in the standing rules that all healthcare support workers are on the voluntary register? If he says that he will insist, then why not have a statutory register? If he will not insist, we will see a patchy response. Of course, none of that will cover the most vulnerable sector of all—nursing homes. We know that, for much of the time during a week, 24 hours a day, the residents of nursing homes are almost wholly dependent on healthcare support workers. This is surely the most vulnerable part of the system.
Finally, on turnover and proportionality, the noble Baroness, Lady Hollins, said it all. She said that rapid turnover was symptomatic of the problem that we have with healthcare support workers. I would argue that one of the great building blocks in boosting the training and status of healthcare support workers would be to introduce statutory regulation. For me, that is probably the most persuasive argument of all.
The noble Earl may offer some kind of review, but, frankly, the time for reviews and for voluntary action has gone. All that could have happened, but it has not, and we have an immediate problem of standards and patient safety. My noble friend Lord MacKenzie said that the amendment is proportionate and is about patient safety. It deserves support.
Before the noble Lord sits down, perhaps I may raise two points with him from his great experience of the health service. First, is it appropriate for the fundamental provision to be an amendment to a statutory order rather than for it to be done through primary legislation? Secondly, on delegation, the amendment states that,
“a health care support worker shall be an individual whose work is routinely delegated to them by a registered nurse or midwife”.
Could not a healthcare support worker have an independent assignment from the employer? In other words, it would be not be delegation from a registered nurse but direct employment on that basis. I would like help on that if possible.
My Lords, when I was in government, I was always very wary of interventions from the noble and learned Lord when he required help on an answer that I had given. I should probably let the noble Baroness, Lady Emerton, answer for herself, but perhaps I may make two points. First, the noble Baroness has been very inventive in using this Bill as a way of raising these concerns. As a number of clauses, to which we shall come shortly, relate to regulation, her amendment is quite in scope. Secondly, this is very much a debate on the principle. I have no doubt that, if the noble Baroness were to press the amendment to a vote and was successful, the noble Earl, Lord Howe, would come back at Third Reading or in the other place with a tidying-up amendment which dealt with the issues that the noble and learned Lord has raised, respecting the intent of the House but ensuring that the statute was as tight as it could be. It is probably not for me to answer for the noble Baroness.
My Lords, this has been another excellent debate about a critical issue: how we ensure that the staff who deliver NHS care have the training, support and appropriate regulation to enable them to do so. I pay tribute to the noble Baroness, Lady Emerton, for her advocacy of this cause, which is of course of central importance.
This amendment would require the Nursing and Midwifery Council to regulate healthcare support workers on a mandatory basis. I hope that I do not need to convince the noble Baroness that we have given this considerable thought. The Government’s view, like that of the noble Baroness, Lady Pitkeathley, is that compulsory statutory regulation is not the only way to achieve high-quality care. It is no substitute for good leadership at every level and the proper management of services, which is perhaps the most relevant issue in the context of the examples of poor care cited by the noble Baroness, Lady Young, to whom I listened with great attention.
Regulation can respond to concerns about the practice of professionals when they arise, but the regulator cannot be in the room all the time. On the other hand, employers are often in a position to act early, when concerns first arise and before harm occurs.
Let us remember that there are existing tiers of regulation that protect service users, particularly the vetting and barring scheme, through which unsuitable workers can be barred from working with vulnerable adults and children. I say to the noble Baroness, Lady Masham, in particular, that that includes where regulated nurses are struck off. If there are concerns that they may pose a risk, they should be referred to the Independent Safeguarding Authority. The Care Quality Commission also enforces standards for providers of health and social care services.
There is no difference between the noble Baroness, Lady Emerton, and the Government on the central issue. We recognise the need to drive up standards for support workers and to facilitate employers appropriately to employ, delegate to and supervise health and social care support workers. To this end, we have commissioned Skills for Health and Skills for Care to work with professional stakeholders on the development of a code of conduct and minimum induction and training standards for healthcare support workers and adult social care workers in England. The noble Baroness has expressed her doubts about that decision, but I noticed with interest that, in its recent addendum to its response the House of Commons Health Select Committee, the NMC stated clearly that it supports the Government’s announcement that Skills for Health and Skills for Care have been commissioned to do this work and to develop a delegation standard for nurses and midwives that will provide an effective framework for public protection.
We confidently expect Skills for Health and Skills for Care to engage with nursing professionals, including educationalists, in taking this forward. There are registered nurses on the proposed membership of the steering group for the work that we have commissioned from Skills for Health and Skills for Care, and I am happy to suggest in response to the noble Baroness that a university lecturer should also be included. More generally, we would expect a broad programme of engagement as part of the work to take this forward. We expect the standards to be agreed ahead of the establishment of voluntary registers for healthcare support workers and adult social care workers, which could be operational from 2013 onwards; so, to be clear, those workers meeting the standards of training and conduct would be able to be included on an assured voluntary register. We will ensure that the delivery of training for health and care assistants who are entitled to be included on a voluntary register is professionally led, and I can confirm that, following this debate, I will be writing to Skills for Health and Skills for Care to make this absolutely crystal clear.
The noble Baroness and my noble friend Lord Newton expressed doubts about whether there would be a system for tracking people when they moved. There was also a question from my noble friend about whether there could be more than one register. Current arrangements for statutory regulation do not enable the regulatory bodies to track the movements of individuals; they rely on the self-reporting of changes of job. A voluntary register would be no less able to do that, and indeed could remove people who failed to notify the regulatory bodies of changes. I would say to the noble Lord, Lord Kakkar, and my noble friend Lord Newton that no decision has been made about whether there will be more than one register. As such, I hope I can provide reassurance first that having assured registers means that this is not an easy course of action, in the way that was suggested earlier, and secondly that the professional standards authority could take account of the existence of multiple registers in determining whether to accredit a further register.
Will my noble friend give way just briefly? I was at the other end of the Chamber, but I have shifted ends. Leaving aside the point about tracking, on the point about whether there will be one or more register I am conscious that, in the area of ombudsmen, there is experience of rival ombudsmen. Frankly, especially since it is in the choice of the provider not the customer, the providers go to the one who they think will give them the easiest ride. I do not want to see that situation here. Serious consideration needs to be given by whatever means to making sure that, if there is a voluntary register, it is one register and not a choice between a good one, a bad one and an indifferent one.
The key here lies in the standards and the training. If we have standards laid down that are uniform across the piece, I am not sure that having more than one register is a significant issue. As I said, this is something that the professional standards authority is bound to take account of when deciding whether to accredit another register.
The noble Lord, Lord MacKenzie, expressed the view that voluntary registration does not work. The Government’s proposals are for assured voluntary registration. We believe that the effective assurance of the standards of healthcare support workers can be delivered by an assured voluntary register that is underpinned by clear standards of conduct and training and supported by the Nursing and Midwifery Council’s updated guidance on delegation.
The noble Baroness, Lady Finlay, asked how standards will be monitored. We will expect the professional standards authority to assure that any standards set for a voluntary register are appropriate as part of its initial accreditation process. It will keep the operation of any register under review and we will expect it to set out any concerns that it has about standards. The authority will also have powers to remove the accreditation of registers if any of its concerns are not addressed in a timely fashion.
The noble Lord, Lord Patel, asked what criteria would apply in individual cases. In its council paper, Voluntary Registers—Proposed Model for the Accreditation Scheme, the CHRE has stated that all voluntary registers seeking accreditation will be required to complete a risk assessment tool that will assess the risks inherent in a profession’s practice and the means by which those risks are and could be managed. The authority will also keep under review the management of risks by an accredited register. That will be part of its role.
However, having listened to the concerns raised in this House, the Government have given further consideration to this whole issue. Once a system of assured voluntary registration has been established for this group and has been operational for three years, to enable it to demonstrate its effectiveness the Government will commission a strategic review of the relative benefits of assured voluntary registration compared with statutory regulation. The review will involve all relevant professional bodies and trade unions. Such a review would include consideration of any further measures needed to assure the safety of patients and the public, including consideration of the case for compulsory statutory regulation or—and I say this in particular to the noble Lords, Lord Kakkar and Lord Hunt—making standards of training mandatory for employers through the use of standing rules for the NHS Commissioning Board and standard contracts for providers.
The noble Lord, Lord Kakkar, raised what I thought was a very astute point about the NHS standard contract. I can confirm that, yes, the Secretary of State will have the power to include in the standard contract the fact that relevant workers must be on a particular voluntary register. We see this as a strong lever, and we would want to consider it very carefully before deciding to use it in a particular instance, but wherever there was clear and demonstrable evidence that doing so would ensure quality of care, we would give it very serious consideration.
I can confirm that the question of whether to move to statutory regulation will be viewed openly, with full consideration of the potential benefits that it might be able to bring. I can say to my noble friend Lord Newton once again that the power to introduce statutory regulation already exists, in Section 60 of the Health Act, if a decision were to be made to deploy it. The Law Commission is in fact consulting at the moment on an even broader regulation-making power in the future. In the mean time, we are committed to exploring the evidence base on ratios of qualified to non-qualified staff. I totally agree with the noble Baroness that this is a key point. We will look carefully at the evidence from ongoing work by King’s College.
I have tried to set out what one might term, picking up a phrase from the noble Lord, Lord Patel, the direction of travel here. I hope that the noble Baroness, Lady Emerton, will understand our commitment to seeing defined standards and improved skills in the healthcare support workforce. The noble Baroness, Lady Masham, asked whether it is not time to have better safeguards in place. Yes, it is. I agree with her. Where we part company is on what a set of new safeguards should be. I strongly feel that a combination of voluntary registration and training is the more appropriate and proportionate solution to what I agree is a problem that needs to be addressed. The work that we have commissioned takes us on that road.
I hope that I have been able to reassure noble Lords of our commitment to strengthening the assurance processes in place for health and social care support workers, and that, perhaps with reservations but nevertheless more confidently than before, the noble Baroness—
I have listened carefully to what the noble Earl has said and there are two areas that he has hardly mentioned—indeed, he has not mentioned one at all—but which he should perhaps refer to. What consideration has he given to the fact that, if you talk to healthcare assistants—and I mean literally hundreds of them—you find that they want this qualification and registration to illustrate the value that they have not just to themselves but also to colleagues around their hospitals? This is also the case for patients: if you do any survey of patients, they say that they want healthcare workers to be registered, so that they understand and have the assurance of that. I wonder how much consideration of those factors has gone into the deliberations that he is talking about.
I apologise to the noble Baroness for not covering that point. We are well aware of precisely that view among the workforce. With the creation of a voluntary register, the process that she refers to will gather its own momentum because people will see the opportunities open to them to accord themselves the status that they clearly crave. It is important, from the point of view of the patient, that hospitals—and, indeed, care homes—are employing people of a certain standard of accreditation and skill. I think, therefore, that this will be self-fuelling and I hope that, once the register is on offer, substantial numbers of healthcare support workers will be encouraged to join it.
The noble Baroness, Lady Howarth, was, of course, quite right, because we have a mix of skills in so many settings. I did not share her view that, if I can put it this way, the skills of social workers were being belittled by the noble Baroness, Lady Emerton—not at all. She was, however, right to point out that the role of social workers can be just as critical for the well-being of patients and service users as the role of a healthcare assistant. We should not automatically think of these skills as medical skills; they are, in many cases, wider than that. We recognise that there are two distinct groups of workers here—that is the reason why we have asked Skills for Health and Skills for Care to work together to define standards of training. Despite the differences between the groups, there will be similarities; we want to tease out what those are and to define them accordingly. I hope that this is helpful. I hope, too, that the noble Baroness will be reassured and feel able to withdraw her amendment.
My Lords, first, I thank all noble Lords who have participated in the debate this morning. It has highlighted and pinpointed one of the essential needs that must be addressed very quickly in terms of the future of the health service. The noble Lord, Lord Hunt, said that he thought that I had probably put down the amendment as it was worded in order to raise a debate. He was right—I was concerned to get a debate raised on the whole issue. It is unfortunate that despite the Bill’s title—the Health and Social Care Bill—social care has not been included yet. We know, however, that social care will come, and I have been a great supporter of mentioning support workers as we have gone through the various briefings. I take the point made by my noble friend Lady Howarth that social workers are just as important as the healthcare support workers. However, I had to draw a line somewhere as to the title of the debate and how we moved it forward, and I thank noble Lords for their contributions.
I have listened very carefully to what has been said, including by the noble Earl, Lord Howe. If I have heard correctly, I think that he has given a reassurance and a commitment about how things might emerge in the next few months in terms of developing the care standards for the training. He has also given an assurance that there will be a review later on, after the establishment of the training, as to whether statutory regulation would be possible or whether voluntary registration had been satisfactory. The noble Earl knows that we have been waiting a very long time for the examination of the regulation of healthcare support workers. I will take away what he has said and I will read very carefully in Hansard what has been said—a lot has been said in nearly two hours of debate—but, for today, I will withdraw the amendment.
Amendment 240 withdrawn.
Clause 208 : Power to regulate social workers etc. in England
241: Clause 208, leave out Clause 208
My Lords, we now move on to another group on the regulation of healthcare workers, and social care workers as well. In debate in Committee, I made it clear that I was concerned about the decision of the Government to abolish the General Social Care Council and to transfer responsibility for regulation of social care workers to the Health Professions Council. I am concerned for two reasons. First, I know that the General Social Care Council had rather a bumpy ride to start with and was the subject of a review, which was critical of the way in which it performed. However, it is right to pay tribute to the tremendous work undertaken in the last two years under its current leadership and the chairmanship of Mrs Rosie Varley to improve and enhance the quality of the regulation by the council. It is very disappointing that the Government have decided that, just at the time when the GSCC is starting to prove itself, the whole thing is to be dismantled and the function transferred to the Health Professions Council.
I also do not understand why the Health Professions Council is considered to be the right regulator for social workers. There is a difference between social work and health work. We touched on that in the last debate. I agree with what the noble Earl, Lord Howe, said in response to the noble Baroness when he reflected on the value of social care workers but also on the difference in role. The Health Professions Council regulates a number of bodies, but they all have a health basis in the main. Therefore, it stretches the imagination to see how this body will effectively regulate social care workers in the future. The profession of social work is pretty fragile and having its own regulator is one of the building blocks for boosting the status, confidence and quality of the social work profession.
I oppose the abolition of the GSCC and the transfer of social worker regulation to the HPC in principle. If I am unsuccessful in persuading the Government, even at this stage, to change their mind, I suggest that a number of issues would help to reassure me and many social workers about the way in which the HPC will perform. This is why I have a number of amendments, which seek to ensure that there is an appropriate definition of “social worker”. I think that it would be appropriate, inside the HPC, to establish an office of chief social worker. I also think that the name of the HPC should recognise that it is regulating the social work profession. I have not yet had any rational answer as to why “Social Work”, or something of the sort, should not appear in the title of the HPC. We know that the reason is that the HPC has refused to have it. I think that the department is finding it difficult to tell the HPC that it is subject to parliamentary provision and that it is not enough, simply because it does not want “Social Work” in its title, not to agree to it. I refer the noble Earl, Lord Howe, to the Bill before us. It refers, in these clauses, to a number of orders, including health and social work orders. Therefore, there clearly cannot be an objection in principle to the use of “Social Work” in the title. It is totemic, but it is at least a way of showing the 100,000 individuals in the social work profession to be covered that in fact the HPC is not going to continue with a medical model of regulation.
My final point is this. I invite the noble Earl to state clearly that it is not his department’s intention that the HPC should eventually take over the regulation of nurses and doctors. He will know that a review is being undertaken of the Nursing and Midwifery Council and I gather that there are also proposals to change the governance of the General Medical Council. A number of people in the health service have told me that they think the eventual aim is for the HPC to regulate all the healthcare professions. The noble Earl would provide a great deal of reassurance if he would say that it is not his department’s long-term ambition to turn the HPC into the sole regulator of all the health and social care professions. I for one would be very concerned about that. I beg to move.
My Lords, I shall speak to Amendment 241C, which is tabled in my name. I also support the amendments tabled by the noble Lord, Lord Hunt. I was tempted to add my name to them, but I was a bit late yesterday. These amendments concern the implications of abolishing the General Social Care Council and the dilution or indeed the elimination of some of the functions carried out by that body. I thank the Minister for the briefing meeting that he held yesterday. At the tail end of this most unpopular of Bills, and after what I gather have been more than 100 meetings with Peers and others, I want to acknowledge the extraordinary work that the noble Earl has done throughout.
The social work profession is perhaps the most battered profession in this country and, if I may say so, the previous Government did not help in that. A certain Secretary of State for Education in the other place took what I thought was completely unreasonable action following the Baby P incident, which left the social work profession pretty much on its knees. The idea of having a chief social worker in this country who would act as a spokesperson for social work—someone who would promote and defend it—is enormously justified at a time when the profession, as I say, is on its knees. It is very difficult to appoint good people because of the reputation of the profession and because of the actions of that Secretary of State. He happens to be a friend of mine, but I think that he made a terrible error on that occasion.
Amendment 241C seeks to ensure that best interest assessors under the Mental Capacity Act continue to have their training regulated. I realise that the Government’s agenda is to reduce regulation wherever possible and I broadly support that objective, because we have had too much regulation in this country. But there are limits to that process and I believe that this is one issue over which the Government have in fact gone beyond a reasonable limit. Post-qualification training is currently regulated by the General Social Care Council, but under the Bill only the training of approved Mental Health Act practitioners will be regulated by the Health and Care Professions Council. Although the GSCC accepts that it could have done a better job with that regulatory power, to do away with it altogether seems to be the absolute opposite of the right answer.
Why is this important? It is because the issue here is often about the deprivation of liberty of elderly patients with dementia and those with severe learning difficulties. Civilised countries always take extra care in protecting individuals where their liberty is being taken from them. It is somewhat arbitrary that these groups happen to fall into the ambit of the Mental Capacity Act on the one hand and that of the Mental Health Act on the other. I am sure that in time those two pieces of legislation will be brought together, but in the mean time we have to manage the fact that people are being detained either under the Mental Health Act or the Mental Capacity Act and that very similar processes are under way in the two sets of circumstances. Mental Capacity Act clients in residential homes or nursing homes, for example, who do not have the capacity to make their own decisions about their lives, are in essentially the same position as psychiatric patients who are not able to make a rational decision about whether they need to be detained in hospital.
Psychiatric patients are assessed by approved Mental Health Act practitioners to determine whether they warrant that detention. In Mental Capacity Act cases, the professional is assessing whether a particular decision is in the best interests of the patient or resident, assuming that the patient does not have the capacity to make the decision for themselves. In both cases this is likely to involve assessing whether the individual can live safely at home. That is the whole point. People are assessing pretty much the same thing under the two different pieces of legislation. It is true that in some cases approved mental health practitioners have to assess the risk to others, but the issues are honestly very similar. Is there any logic, therefore, in regulating one and not the other? We know that abuse of these adults is commonplace. Relatives may of course be absolute angels in terms of protecting their family members, but they may not be, and the best interest assessor is there to protect vulnerable people when relatives let them down.
The words of Mr Justice Peter Jackson in his ruling in the London Borough of Hillingdon v Steven Neary and Mark Neary and the Equality and Human Rights Commission highlight the importance of the deprivation of liberty safeguards. The deprivation of liberty safeguards were designed to protect the human rights of some of our most vulnerable people. Employers and supervisory bodies have to be sure that the professionals they charge with undertaking this vital role are competent, compassionate and able to approach the situation from both a practice and legislative basis. With the closure of the GSCC, I urge the Minister to put in place a system at least as robust as the current one, and ideally more robust, to ensure that the providers of training for best interest assessors can clearly demonstrate their ability to produce and, importantly, assess potential best interest assessors. That would go a long way towards protecting some of these very vulnerable citizens.
I want to turn briefly to a number of the amendments tabled by the noble Lord, Lord Hunt. The first concerns student registration, which we discussed in detail at the briefing meeting yesterday. I shall not go into all the detail again. However, it has to be said that if it is justified to register social workers, it has to be justified to register social work students. That is because these people are unknown and untried. They go into vulnerable people’s homes on their own and they are probably more of a potential risk to their clients than qualified social workers. There is once again an issue of logic here, which I hope the noble Earl will take seriously.
A further concern is that, as I understand it, the Health and Care Professions Council will not introduce the satisfactorily assessed and supported year in employment as a requirement before someone can be accredited as a fully qualified social worker. This is another important safeguard, as people have to prove themselves over the course of a year’s work. There is no great administrative problem about this. It is simply a requirement so that employers meet certain standards. I would argue that it is not a bureaucratic nonsense; it is an important requirement.
Finally, there is to be no regulation of social care workers. The arguments that were rehearsed in the previous debate probably apply just as much to this one. The case for statutory regulation where vulnerable people and low-paid workers are concerned seems absolutely overwhelming. Again, I hope that the noble Earl might agree also to have a review of this area. At the minimum, is the process of voluntary regulation really working?
I fear that the Government have gone too far in dismantling the protections for vulnerable clients. Of course employers and universities have important responsibilities for their workers and clients, but I hope that even at this late stage the noble Earl might want to maintain some state responsibility for the protection of these most vulnerable clients when their liberty may be taken from them.
My Lords, if the noble Earl thought I was being unkind to the noble Baroness, Lady Emerton, he may think that I am being even more unkind when I come to address him. I want to make it absolutely clear that I was asking the noble Baroness whether she had seen the defect in her amendment. Delegated powers would go from health professionals to the social care professionals and not from the social care professional leaders in establishments down to social care providers. That was a significant defect which I think the noble Baroness herself noted, as did other noble Lords, during the course of the debate. That was all I was raising but it leads on to this debate about the social care profession and how it is valued when compared with other professions. That is why this debate, at this moment, is crucial to social workers.
I ask the Minister this question. Is it the Government’s intent to remove the profession of social work from the nation’s vocabulary? That may sound an unkind question, but social workers are beginning to feel that they do not belong anywhere. Their name is not in any of the Bills. Indeed, their professional organisation is being wiped out, as they see it. I will not repeat the points made my noble friend Lady Meacher about some of the protections around people practising and training with clients. They have to practise alone. They are not supervised day-to-day by having someone with them who is also registered in a proper way. All of these things undermine the profession.
When the Conservatives were in opposition, the Conservative Party set up an inquiry to look into social work, taking the view that it wanted to encourage and enhance the social work profession. I was very grateful and felt that it had made a real difference to the way that social workers were valued. In that inquiry, the Conservative Party acknowledged the difficult work that social workers undertake with disruptive families, the mentally ill, children, the disabled and those with learning difficulties—in fact most of the groups in our society that other people do not wish to have to deal with day to day. Those people can be intransigent, difficult and often stubborn and social workers have to develop new skills in order to move families on into change, particularly in the present environment. That moved on to the Munro review of child protection and the hope that social workers would gain more control over their lives and the way that they worked, lessening the bureaucracy and enabling them to do more.
However, to have their designated regulatory body removed and to be absorbed into what they see as a healthcare organisation will detract from all of that. The people you meet out there who are involved in social work worry about where they stand in terms of the whole of the social care sector. If you talk to them alone, you will find that they are pretty low, depressed and fragile and that affects the way that they carry out their work. It affects the enthusiasm and joy with which social work can be carried out.
I am having real difficulty. Perhaps the clerks will recognise that. I do not want to speak at length because what I have said is to the point. I will not go through the amendments. Other noble Lords will do that in detail. Of course, a principal social worker would make a difference. In a former position, the noble Lord, Lord Laming, made a huge difference to the social work profession. It felt that someone, somewhere, was there on its behalf. We have people in the Department of Health, but they are not given the strength and status that Herbert had when he stood in that position and made that difference.
There were difficulties with the regulator, but I have just spent eight years working in another organisation that had difficulties. If you work hard enough and long enough, you can get it right. It is not right to give up in the middle and to change things so fundamentally that people do not recognise that it has anything to do with them. Certainly, social workers are not recognising that the new regulator will have anything to do with them.
I am sorry to speak so strongly and so generally but, sooner or later, someone has to speak up for those people who are doing what I call the dirty work of the nation on behalf of all of us. It may be that my cold is not helping and I am not my usual gentle self, but I feel extraordinarily strongly that, unless the Government take it upon themselves to encourage and make social workers feel valued, understand their work and differentiate them from the medical care area, we will have fewer social workers of ability on the ground and they will make more mistakes. More mistakes will mean more difficulties for children and old people, never mind the field day that the press will have, and we will be on a downward spiral. I ask the noble Earl to look at the issue that the noble Lord, Lord Hunt, is raising and to do what he can to stop that from happening.
It is a great pleasure to follow the noble Baroness, Lady Howarth, who I deservedly call my noble friend. I very much hope that the Minister will give her the assurances that she seeks. With regard to my noble friend’s amendments on the General Social Care Council, I take the view that we are where we are, however much I wished that different decisions had been taken. Noble Lords will appreciate that, as the first chair of the General Social Care Council, I would say that, wouldn’t I?
However, I take this opportunity to pay tribute to the councils and staff of both the General Social Care Council and the Health Professions Council for the professional and mature way that they have approached the difficult situations in which they found themselves. Their behaviour has been an example to us all and particularly, as far as concerns the GSCC, the fact that high staff morale has been maintained throughout this process is nothing short of a miracle and a great tribute to its leadership.
I agree with other Lords who have called the social work profession fragile. It needs to be promoted and defended if we are to maintain and extend the recruitment that the noble Baroness, Lady Howarth, has reminded us is so important for those people who do the difficult work in our society—which is rarely recognised until the tabloid press attacks it. I must draw your Lordships’ attention to the College of Social Work, which has just been established, which will have the promotion and defence of this fragile profession as part of its remit. It has had a difficult start, as is well known, but I believe that it has the potential to promote and support the profession to which we are all so indebted.
My Lords, I have my name to two amendments in this group. They do not affect social work and therefore I have waited to intervene until the debate on social work had been completed.
I want to discuss two groups: clinical perfusion scientists and clinical physiologists. The clinical perfusion scientists are responsible for the single most invasive tool used in surgery today and are routinely responsible for the administration of potentially fatal controlled drugs. The numbers are small—there are only 350 clinical perfusionists—and they operate in a regulatory vacuum; they are the only non-regulated members of the cardiac surgical team. Yet their management routinely involves significant life-threatening risks to patients daily. Because they are not a regulated profession, in July 2009 the Department of Health produced a good practice guide to clinical perfusion in response to the Gritten report of 2005. It states that the Government fully recognise the need for clinical perfusionists to be regulated by statute and it draws attention to the fact that the document is an interim measure until they are subject to statutory regulation. Indeed, the document states that this has implications in law for their role in working with medicines.
Since the Gritten report in 2005, about a quarter of a million cardiac patients have had their hearts stopped for surgery by perfusionists, who use highly toxic substances and blood products. They feel that they need statutory regulation so that they can be supplementary prescribers, as there is a questionable legality at the moment around drug administration. They are in a unique position. It is this supplementary prescriber role that causes them much concern, because they would like to be assured that what they are doing falls fully within the Medicines Act. I hope that when the Minister responds he will be able to explain quite clearly precisely how, if they are not subject to a statutory register, everything they do complies fully with the Medicines Act.
As for assessing the risk and the need for a profession to be registered, the review of the Professions Supplementary to Medicines Act was debated in another place in 1999. The key test stated in that review is,
“whether there is the potential for harm arising either from invasive procedures or application of unsupervised judgement made by the professional which can substantially impact on patient/client health or welfare”.
In response to that test and in relation to clinical perfusionists, the right honourable Andrew Lansley, said:
“It seems to me that perfusionists entirely match that criterion”.
It seems odd, having had that debate and that being on the record, that clinical perfusionists are still trying desperately to argue that they should be subject to statutory regulation and feel that they are failing to achieve that.
The other group that I want to discuss is clinical physiologists. I suggest again that they fall within that criterion. They are a very skilled group of people who are often alone with patients, including children, in situations in which they are responsible for conducting sometimes complex investigations and interacting closely with whoever is the patient in front of them. For the past 10 years, they have had a voluntary register, which they feel is flawed and demonstrates the need for statutory regulation. As a group they will not gain either in status or financially by having a statutory register. They want it because they are concerned about patient safety. Their view is that there is currently no incentive to register; they are in short supply anyway and can get another job without too much difficulty.
As a group, they sent me an individual case study, which I found quite worrying. I will try to summarise for the House briefly, because this is Report. They cited a clinical physiologist who had been working unsupervised in a room alone with children and working one to one with them. Following a holiday to Amsterdam, he was found to be in possession of child pornography, prosecuted and placed on the sex offenders register. Among his papers, the police found that he was a clinical physiologist and alerted the appropriate group. They alerted the employers but discovered that even though he lost the job he was in, he was rapidly re-employed in another hospital, which they also alerted. They followed it up to find that he had changed his name and, under another name, again had sought employment. They are very concerned that this is one they know about but that there may be others they do not know about. The group does not see how its voluntary registration system gives patients and the public the protection that they ought to have.
My Lords, I support the amendments in the names of my noble friends and Amendment 254 in the name of the noble Lord, Lord Hunt of Kings Heath. Clinical physiologists have had voluntary self-regulation for years and they say that it is not as effective as statutory regulation. They have been trying to get statutory regulation since 2004. All clinical physiologists work independently, and while the overall standard of practice is high there is a significant level of risk to patients as practitioners provide services that directly affect the diagnosis and management of patients. Most patients are unaware that clinical physiologists are not statutorily regulated when they are undertaking invasive or high-risk procedures. The clinical physiologists say that there are about 10,000, of which only about half are voluntarily registered. This debate for clinical physiologists has been running on for too long. They are getting frustrated. They want better patient safety, which they feel statutory registration will help to provide. They feel that the Government could easily give them this. I ask the Government: why not? They are a significant and important group doing work with a high risk to patients.
My Lords, I, too, support these two amendments on the regulation of clinical physiologists, and I think that the case my noble friend Baroness Finlay made about clinical perfusionists is extremely strong.
Clinical physiologists work across a wide range of disciplines. Some work in cardiac investigations, some in respiratory investigations, some in gastrointestinal investigations, but my particular interest relates to clinical neurophysiologists, who carry out a wide range of different investigations involving patients.
Many years ago in my early days as a neurologist, I was involved in the interpretation of electro- encephalograms, and I also introduced into the north-east a technique of electromyography, which is a means of identifying and studying the electrical activity of muscles in health and disease. In all these activities, I was supported by well-trained clinical physiologists. In those early days, those individuals quite often became members of the EEG society, as it was called, of which I was a founder member.
Later, as the interests and the techniques broadened and became much more extensive and much more sophisticated, that organisation, which included doctors working in the field as well as the people called technicians, who were in a sense clinical physiologists, changed its name to the British Society for Clinical Neurophysiology, and the so-called technicians became part of a body called the Electrophysiological Technicians Association—the EPTA—an organisation that later became the Association of Neurophysiological Scientists. It is now very well trained. It works not only in EEG and EMG but in techniques including evoked potential recording, peripheral nerve studies—the measurement of nerve conduction velocity as an aid to diagnosis in disease—and techniques of magnetoencephalopathy. A whole series of new techniques has been developed in which these clinical scientists or clinical physiologists—technicians as they once were—are very deeply involved. They are sufficiently well organised in their professional bodies, which represent their interests, and in the voluntary registers, of which many of them are already members, that they fully deserve registration under the Health Professions Council. Such a statute is long overdue. For that reason, I strongly support the amendments.
My Lords, Amendments 253, 254 and 255 concern various clinical scientists, particularly clinical physiologists. In Committee, I declared an interest in that I have received skilled care from clinical physiologists for nearly five years in monitoring my pacemaker. From 2008 to 2010, when the previous Government were in office, I asked four Questions for Written Answer, pointing out that the Health Professions Council had recommended in 2004 that clinical scientists be included in its regulatory regime. This recommendation was accepted by the Secretary of State at the time. The Answers that I received respectively from my noble friends Lady Thornton and Lord Darzi said, in impeccable ministerial speak, “This will be done not this year, perhaps next year, but certainly some time”. However, the noble Earl, Lord Howe, suggested in Committee that it would be sufficient to continue the voluntary registration scheme that exists now.
Perhaps I may read a small extract from a note sent to me by the Registration Council for Clinical Physiologists, which compiles a voluntary register. The council states that it has,
“substantial evidence suggesting that voluntary self-regulation is not effective for clinical physiologists. Our register has no power of enforcement and is completely toothless because it cannot protect patients from continuing to be treated by practitioners who have not been registered and who are potentially unfit to practise. Where a complaint is made and upheld about a practitioner, he or she usually ‘disappears’ from the voluntary register, which means it is impossible for the RCCP to do further investigations, while the practitioners under investigation are able to find employment elsewhere”.
The noble Baroness, Lady Finlay, gave an example of precisely that. Surely that should not be allowed to continue, and I hope that the noble Earl will reconsider his position and agree that statutory registration is the way forward for this very important group of skilled health professionals.
My Lords, the amendments deal with two discrete areas. The first set of amendments relates to our proposal to establish a system of assured voluntary registration and seeks to extend compulsory statutory regulation to clinical perfusionists and clinical physiologists, and to make further amendments to legislation to account for this.
The second set relates to the transfer of the regulation of social workers in England from the General Social Care Council to the Health Professions Council, to the protection of the function of social workers, to the office of the chief social worker and to the approval of the training of best-interests assessors. Also included in this second group is a minor and technical government amendment intended to correct an inconsistency in drafting.
As for assured voluntary registration, the vast majority of workers give the very highest quality of care. However, a minority let patients down. This is a cause for concern for all of us and it is right that there is discussion about how we can ensure high standards of care. The Government’s view is that compulsory statutory regulation is not the only way of achieving this and can detract from the essential responsibility of employers to ensure that any person whom they appoint is suitably trained and competent for the role.
As I reminded the House earlier, there are already existing tiers of regulation that protect service users, including the standards set by the Care Quality Commission and the vetting and barring scheme. We also need to be clear that professional regulation is not a panacea. It is no substitute, as I said previously, for good leadership at every level and the proper management of services. It can also constrain innovation in some circumstances and even the availability of services.
Experience clearly demonstrates that a small number of workers who are subject to compulsory statutory regulation from time to time fail to ensure that their practice is up to date and delivered to the standard that we expect. In these circumstances, it is too often the case that regulation can react only after the event. The regulation of individuals will not prevent another Mid-Staffordshire, but strong and effective leadership of the workforce may do, and we believe that employers and managers who are closest to the point of risk must take responsibility for ensuring standards.
The Government believe that a system of assured voluntary registration will support commissioners, employers and supervisors to deliver their responsibility for assuring standards by providing independently assured standards of conduct and training for those on accredited registers. We believe that this approach will work well for clinical physiologists, clinical perfusionists and other groups of health and social care workers. Here, we are building on the work started under the previous Government.
The noble Baroness, Lady Finlay, is right that clinical perfusionists are not subject to statutory regulation, but I assure noble Lords that where failures or risks on the part of clinical perfusionists have been identified in the past, action has been taken action to address them. The Department of Health issued guidance in 1999 that the NHS should use only accredited clinical perfusionists, and further guidance in 2009 that clarified the systems and processes needed to ensure high-quality perfusion services. However, employers, commissioners and patients currently have no objective or independent way of determining how robust the accreditation arrangements are, as they not subject to independent scrutiny. In future, if the voluntary register is accredited by the PSA, they will be subject to such ongoing independent scrutiny.
The noble Baroness, Lady Finlay, asked me about the administration of drugs by perfusionists and compliance with the Medicines Act. Perfusionists cannot prescribe drugs, although they do of course administer perfusions. I would say in my defence to the noble Baroness that compliance with the Medicines Act is rather a technical legal point. If she will allow, I am happy to write to her on that legal position.
Both she and the noble Baroness, Lady Masham, indicated their view that voluntary registers already exist and do not work. Voluntary registers do exist, so standards for these professions exist as well. It has to be said that the Department of Health has little if any evidence of a general problem with the standards of practice for these groups, but, as I said previously, we currently have no objective way of saying to employers that if they rely on professionals who are on existing voluntary registers they can be sure that they are meeting appropriate standards. In future, where voluntary registers are accredited by the Professional Standards Authority, that will be possible.
For unregulated groups, the key to ensuring consistent care is good recruitment, good training, delegation and supervision by employers. We believe that our new system of assured voluntary registration would assist them in taking local responsibility for the quality of their staff.
Various noble Lords talked about the removal of unsatisfactory or dangerous people from the register. We would expect the professional standards authority’s criteria for accreditation to include having proportionate methods for removal from the register. It is not clear to me why an individual could not be removed from a register if there is clear evidence that they are failing to meet the conditions set down for registration and due process has been followed. Further, if an individual has been found in possession of child pornography, which was the example given by the noble Baroness, Lady Finlay, they should be referred to the Independent Safeguarding Authority, and they could be barred from working with vulnerable adults and children. There is no reason why that should not have happened in that instance. Employers should undertake identity checks, and that applies whether or not an individual is statutorily regulated.
Let me be clear: we are not ruling out compulsory statutory regulation for the groups mentioned in the amendments. As part of its process of assurance of accredited voluntary registers, the professional standards authority will continue, through its reviews, to monitor whether risks are being satisfactorily controlled within the context of the wider framework of public assurance. The authority will therefore be well placed to assess whether any further regulatory action is needed. I am sure it would advise the Government accordingly.
I will turn now to the amendments which relate to the social work profession in England, which is where the noble Lord, Lord Hunt, started us off. I want to assure noble Lords that the Government are committed to the development of the social work profession. We see strengthening the regulation of social workers in England playing a key part in the reform of the profession. In 2009, following the discovery of a backlog of conduct cases, a report by the Council for Healthcare Regulatory Excellence found potentially dangerous failings in the GSCC’s carrying out of its conduct function. The report recommended that the regulation of social workers in England move closer to the model of regulation used for healthcare professionals. Through the General Social Care Council under its new leadership, progress has been made in developing the organisation since 2009. However, there is still work to be done to bring it into line with the health profession’s regulators.
The noble Baroness, Lady Pitkeathley, made the point here. We do recognise that social workers in England need a strong voice. We support both the development of the College of Social Work and the recommendation of the Munro review for a chief social worker. The role of the college is to be the voice of the profession and lead on professional development, whereas the chief social worker will advise Government on the development of social work policy and practice. However, the role of a regulator is to assure the safety and quality of the individuals on its register. A direct role in supporting workforce development or promoting the profession is likely to present a conflict of interest for a regulator.
The reforms to the regulation of social workers in England form part of a wider package of reforms aimed at strengthening social work. Social workers in England will benefit from regulation by the HPC in a whole variety of ways. They will be regulated on the same basis as other professionals. They will benefit from a truly independent regulator. They will, for the first time, have a set of standards of proficiency, many of which will have been tailored specifically for their profession rather than covering the full range of jobs in social care. They will also be subject to a fitness-to-practise process, which will be able to consider their conduct and competence in the round and which will enable a more rehabilitative approach to be taken by the regulator. This is all in contrast with the GSCC which can only admonish, suspend or remove from its register. The HPC has established a professional liaison group, whose membership includes representatives of social workers, their employers and those involved in their education and training, which has developed draft standards of proficiency for social workers in England. The HPC is currently recruiting social workers as partners, subject to the passage of the Bill. These partners will have a role in the council’s approval of training and education, in considering fitness-to-practise cases and in assessing social workers’ continuing professional development. This will, in combination, help to ensure that the HPC is aware of the nature and proposed development of the social work profession and is able to reflect this in a sensitive way in the standards set for social workers.
The noble Lord, Lord Hunt, asked me whether I could confirm that the HPC will not be covering all professions in the future. I can confidently assure the noble Lord that there is no intention to bring all of the health professions within the scope of the HPC. I myself have received no hint of that within my department.
Will the noble Earl accept that, as the noble Lord, Lord Rea, said, clinical physiologists, and in particular clinical neurophysiologists, have been aware for years that they have produced a very satisfactory standard of voluntary regulation and registration? They have been talking about the possibility of achieving statutory regulation for years. It has been hinted at by Government after Government. They now feel very strongly that the failure of Governments to accept their need for statutory regulation is, in a sense, a kind of downgrading of the status of their respective professions alongside other professions of individuals who work with patients which are regulated by the Health Professions Council: physiotherapists, occupational therapists, and many more. They feel that it is in fact a mark of a lack of respect by the Government that they are being refused statutory registration.
I hope that it is in order to ask the noble Earl a question. When he was talking about the registration and regulation of clinical physiologists, he spent quite a long time saying how voluntary registration could be improved and how good and suitable it was, but he has not actually said why the Government have such a big objection to statutory regulation. I do not quite see why the Government are so unwilling to go ahead immediately with this.
My Lords, if the clinical physiologists feel as the noble Lord, Lord Walton, says they do, I would simply urge them to read what I have said about the merits of assured voluntary registration. It is true that this issue has been on the table for a number of years. The difference between the start of that debate and the point that we have now reached is that there is more than one option on the table. Assured voluntary registration did not exist 10 years ago, but it is now about to become a reality. We come back to the basic point that regulation in itself is not a panacea. Those who think it is need to examine those cases where failures of care and services have taken place. It is much more about upskilling people, making sure that employers are aware of their responsibilities and ensuring proper supervision in the care setting.
The noble Lord, Lord Walton, raises the point that the physiologists may well feel themselves to be treated as a second-rate profession. One of the finest things about the Bill is the way in which it extends the whole concept of treatment to people beyond those who are registered members of the medical profession, to those who belong to professions ancillary to medicine. I wonder whether the noble Earl might take into account the fact that we really need to move towards equal status between people who are involved in the profession, including in the commissioning groups, where some of those who will be on the governing bodies will be people who are not themselves doctors, but who are crucial to delivering an integrated medical outcome. I think the noble Lord, Lord Walton, has made the point that registration has become, in a sense, almost a recognition of status. I see that point.
I very much agree with my noble friend that we want to see a breaking down of silos, if I can put it that way, and a mutual respect and dependence appearing at commissioning level. I am not aware of any examples of clinical physiologists or perfusionists being involved in the commissioning of care. On the face of it, that seems unlikely, although not impossible; I would not rule it out. I take my noble friend’s point about our general wish to see a raising of quality not only in commissioning but also in the provision of care. It is a point well made.
The Minister has spoken about assured voluntary registration being available now. He has said that the Government will monitor it and, if gaps are revealed, would then reconsider statutory registration. It strikes me, first, that we need to know what the criteria are that would trigger moving from an assured voluntary register to a statutory register and, secondly, that these professional groups are in a Catch-22 situation. They have been seeking statutory regulation to drive up and maintain high standards of clinical care. They have been doing all that they can to maintain high standards of clinical care. If they carry on being able to maintain those high standards, gaps will not be revealed. The only way that gaps might be revealed is, in fact, if they drop their standards. It seems like a Catch-22 situation, but I think that I have probably misheard the Minister.
We are talking about controlling risk. The noble Baroness is right that the Government will retain an open mind about statutory regulation. I hope that that is clear. We have not closed the door to that by any means. However, clinical physiologists, for example, say that risks are apparent to them which some clinical physiologists pose to patients. We have never seen evidence of those risks. In the past, when the Health Professions Council made recommendations about regulation, it has not considered risks. However, we agree with the previous Administration that the extension of regulation should be based on risk. That is the key point. If it is shown that, notwithstanding everybody’s best efforts, assured voluntary registration has not been sufficient to protect patients then, of course, any responsible Government would wish to see a strengthening of the measures around registration.
I revert now to social workers, as I hope that I have covered the points raised. We can most effectively bring improvements to the regulation of social workers in England by transferring their regulation to the Health Professions Council. To answer the noble Lord, Lord Hunt, it may well be that the GSCC could have delivered improvements in the way that social workers are regulated. However, reforming the GSCC’s procedures to ensure that they were fit for purpose would have taken time and, I can tell the noble Lord, would have required very considerable resources. The cost involved, among other considerations, would have been prohibitive.
The Health Professions Council is an established and effective regulator. The proposed transfer of functions to it would bring a number of benefits to the regulation of social workers in England, and I have outlined those. The name “Health and Care Professions Council” was decided upon with reference to the views of the Social Work Regulation Oversight Group, of which both the chair of the Social Work Reform Board and the chief executive of the GSCC are members. As part of the process of renaming the Health Professions Council, the name “Health and Social Care Professions Council” was considered. However, following research commissioned by the Health Professions Council, it was decided that the name “Health and Care Professions Council” most effectively reflected the new remit of the council in a way that was clear to the public, registrants and employers, while maintaining name recognition for service users, employers and registrants. However, to ensure even further clarity for the public, the Health Professions Council’s new name will be supported by a strapline: “Regulating health, psychological and social work professionals”, so it is not as though “social work” has been omitted entirely from the heading of this organisation.
We also need to ensure that the regulation of social workers in England is flexible enough to enable the regulation of all the activities which a social worker may undertake, now and in the future, and to take account of developments in the profession. It is not, therefore, practical to protect the functions of social workers in England in legislation. Protection of title has ensured that the regulation of professionals can readily adapt to changing roles over time. It also prevents regulation being used in a protectionist way to keep certain functions as the preserve of a specific group of workers. Although we do not think it right to protect the functions of social workers in England for the purposes of professional regulation, we recognise that for the profession to flourish it needs a clear purpose. We are therefore pleased that the College of Social Work has committed to providing clarity on the role of social work in England.
I can give the noble Lord, Lord Hunt, and the noble Baronesses, Lady Meacher and Lady Howarth, some good news, to which I referred briefly, on the position of chief social worker. As they will be aware, the Government have accepted the recommendation that a chief social worker be appointed. We expect that the chief social worker will be in post by the end of this year. Our view is that the office should not be established in statute; this is the approach that we have taken with the Chief Nursing Officer and the Chief Medical Officer, and one that we believe has worked well. Of course, it is the Government’s expectation that the chief social worker will work closely with all key social work partners, including those mentioned in the noble Lord’s amendment. It is also vital that the role should be transparent, and we are therefore open to the suggestion that the chief social worker should lay an annual report in Parliament. However, we would wish to take a final view on that once the chief social worker had been appointed.
On social work students, raised by the noble Baroness, Lady Meacher, we are mindful that there should not be a gap in the assurance of the standards of social work students. We intend to provide for the transfer of the voluntary register of social work students to the Health and Care Professions Council pending a full consideration of the best approach to assuring the safety and standard of student social workers. The Health Professions Council has committed to undertaking a review of the risk in relation to students of all the professions it regulates, including social work students.
The noble Baroness also mentioned post-registration training. It is the role of the regulator to ensure that its registrants remain fit to practise and that the Health and Care Professions Council has a rigorous risk- based approach to ensure that appropriate continuing professional development is being undertaken. I would be happy to write to her with further details about that.
The noble Baroness, Lady Meacher, raised the important issue of best-interest assessors. I want to be clear that we very much value the important work that they do, working with some of the most vulnerable members of our society. As she will know, we have already set standards of those who are, or wish to become, best-interest assessors, including requiring that all best-interest assessors are members of a profession subject to compulsory statutory regulation and undertake training approved by the Secretary of State. Unlike the training of approved mental health professionals, the GSCC currently has no statutory role in approving the training of best-interest assessors. Therefore, we cannot simply transfer the role to the HPC as we have with approved mental health professionals. However, we are aware that the abolition of the General Social Care Council will impact on the current process for approving best-interest assessor courses. We are considering how it should work in the future, including the development of competencies for best-interest assessors, and whether the Health and Care Professions Council should take a role in approval of education and training of best-interest assessors. Until this consideration has been completed, it would not be appropriate to make changes to legislation. If I may, once again, I will write to the noble Baroness on that issue.
Before I finish, I speak to government Amendment 246A, which is, I can assure the House, a minor and technical drafting correction. I hope that I have been able to reassure noble Lords of our commitment to strengthening the assurance processes in place for health and social care workers, and that the noble Lord will feel able to withdraw his amendment.
My Lords, I thank the noble Earl for his lengthy response, particularly in relation to clinical psychologists and clinical perfusion scientists. I am sure that noble Lords will have noted with interest his remarks, and indeed we have had further discussions about it. The debate has shown that there is a weakness in the continuation of voluntary regulation that will not go away.
Turning to social work regulation, I must say that I am disappointed by the noble Earl’s response. Unless this is a Department of Health contribution to the review of public bodies and it is simply a way of getting the number it is responsible for down, I still do not understand the logic. There is no doubt—here I pay tribute to my noble friend for her sterling efforts, which have been continued by Mrs Rosie Varley—that the General Social Care Council was getting to grips with the issues identified in the review, so I cannot understand why it could not have continued. The advantages mentioned by the noble Earl in relation to the HPC could all have been developed by the GSCC. I come back to the points raised by the noble Baronesses, Lady Howarth and Lady Meacher, about the fragile confidence of the social work profession. Replacing its regulatory body with an all-singing, all-dancing essentially health body is not the best way to give it confidence.
On the title, I do not think that a strap-line is good enough. I simply point out to the Minister Clauses 216, 218, 219 and 220, which refer to the health and social work professions order. All the spurious arguments that have been made as to why this body cannot have social work in its title are given the lie by the fact that in this legislation the noble Earl is relying on that order. I would have thought that if the HPC was serious about wanting to develop confidence within the social work profession, it would have agreed to have the words “social work” in its title. However, I will not press Amendment 241A concerning the protection of the functions of social workers.
Amendment 241 withdrawn.
Amendments 241A and 241B not moved.
Clause 209 : Training etc. of approved mental health professionals in England
Amendment 241C not moved.
Clause 210 : Orders regulating social care workers in England: further provision
Amendment 242 not moved.
Clause 211 : Abolition of the General Social Care Council
243: Clause 211, leave out Clause 211
Clause 212 : Regulation of social workers in England
Amendment 244 not moved.
Clause 213 : The Health and Care Professions Council
Amendments 245 and 246 not moved.
Clause 214 : Functions of the Council in relation to social work in England
246A: Clause 214, page 212, line 38, leave out “, after sub-paragraph (c) insert—” and insert “—
(a) omit the “or” preceding paragraph (c), and(b) after that paragraph insert “; or””
Amendment 246A agreed.
Amendment 247 not moved.
Clause 215 : Appeals in cases involving social workers in England
Amendment 248 not moved.
249: After Clause 219, insert the following new Clause—
“Public health specialists
(1) In section 25(3) of the National Health Service Reform and Health Care Professions Act 2002, (regulatory bodies regulated by the Council for the regulation of health care professionals), after paragraph (j) insert—
“(k) those statutory bodies responsible for the regulation of public health specialists including those from backgrounds other than medicine, for whom a statutory register will be established by the Health Professions Council.”(2) In this Act “registered public health specialist” means a person recognised as such on a register maintained by those statutory bodies responsible for the regulation of public health specialists, including those from backgrounds other than medicine.”
My Lords, Amendment 249 is related to statutory registration. We have been talking about voluntary or statutory registration for the past three hours. I shall be happy if at any time the noble Earl interrupts to stop me trying to make a case for statutory registration for public health specialists because he has already made up his mind that he is likely to accept if not this amendment then statutory registration. I believe that the noble Baroness, Lady Northover, is trying to intervene.
My Lords, a great deal of attention has been paid to public health in this House and we very much welcome that and the efforts by the noble Lord, Lord Patel, and others. We recognise that public health specialists play a critical leadership role in protecting the public from harm. The Government recognise the strong support for a compulsory statutory regulation system for all public health specialists. I think that that is what the noble Lord was going to say. We agree that it is absolutely essential that all public health specialists, including those not currently subject to compulsory statutory regulation—
The noble Lord has not moved the amendment.
Noble Lords will know that the Government have already announced their intention to regulate all public health specialists so that we address the anomaly whereby some were regulated and others were not. If that is the answer that the noble Lord was looking for, put briefly, I hope that he will welcome it.
I welcome those comments. As I understand it, the noble Baroness, Lady Northover, is saying that the Government intend through secondary legislation to establish statutory regulation of all public health specialists, including those not in medicine and dentistry. I am grateful for that. I beg leave to withdraw the amendment.
Amendment 249 withdrawn.
Clause 220 : Functions of the Secretary of State in relation to social care workers
Amendment 250 not moved.
Clause 221 : The Professional Standards Authority for Health and Social Care
Amendment 251 not moved.
Clause 222 : Functions of the Authority
Amendment 252 not moved.
Amendments 253 to 255 not moved.
Clause 233 : Quality standards
Amendment 255A not moved.
Clause 236 : Advice, guidance, information and recommendations
256: Clause 236, page 236, line 29, at end insert—
“( ) But provision made under subsection (8) may impose a requirement on a local authority, or a description of local authorities, only if the requirement relates to—
(a) the exercise by an authority of any of its functions under section 2B or 111 of, or paragraphs 1 to 7B or 13 of Schedule 1 to, the National Health Service Act 2006;(b) the exercise by an authority of any of its functions by virtue of section 6C(1) or (3) of that Act;(c) anything done by an authority in pursuance of arrangements under section 7A of that Act.”
My Lords, I shall speak also to Amendment 257. I have tabled the two amendments for the following reasons. The Bill makes provision for local authorities to fund public health drugs and treatments. It also enables provision to be made for the replication of the funding direction to require the NHS to make available funding for NICE-recommended drugs and treatments. However, as currently drafted, the provisions in Clause 236 to enable replication of the funding direction for NICE-recommended drugs and treatments currently exclude their application to local authorities. Subsections (8) and (9) make provision to enable replication in regulations of the effect of the funding direction that currently requires PCTs to make funding normally available for drugs and treatments that have been recommended by NICE technology appraisal guidance. The amendment would permit other bodies that fund public health services to finance these suggestions as PCTs are phased out of the system, creating a more uniform and streamlined system for patients to manoeuvre through the different health services offered.
As the Bill currently stands, it is impossible for regulations to require local authorities—which take on health functions under new paragraphs (a), (b) and (c) in my Amendment 256—to comply with NICE recommendations to fund such proposals. While these local authorities are likely to be responsible for the funding of such treatments under their public health functions, without codification of their ability to do so in the Bill, there will be no authority to take over the funding of such recommendations to which PCTs remain currently obligated, thus creating a gap in care as health functions are transferred between PCTs and local authorities.
Furthermore, as enshrined in the NHS constitution and its accompanying handbook, NHS organisations are also required by a direction from the Secretary of State to finance drugs and treatments suggested by NICE which are based on sound research evidence. Although the funding direction concerns mainly high-cost drugs or treatments used in NHS secondary care, there have been two or three NICE appraisals that concern public health drugs and treatments. For example, NICE has appraised and recommended a smoking cessation drug, Champix—noble Lords will know of my interest in smoking—which is currently covered by the funding direction. To ensure that this gap in funding does not occur, my amendments would extend the scope of the regulation-making power, enabling requirements to be placed on local authorities exercising their public health functions so that the effect of the funding direction which currently applies to NHS organisations could apply also to them. It is important to note that, while local authorities will have the ability to fund NICE recommendations, this extension relates only to matters dealing with public health. Moreover, regulations will be unable to place a requirement on local authorities to comply with or have regard to NICE recommendations relating to social care, putting limitations on the funding capabilities of local authorities.
The amendments would remove the exclusion of local authorities and enable provision to be made in regulations for the requirement to fund to apply to them in relation to NICE-recommended public health drugs and treatments. They would place a requirement on local authorities to exercise their public health functions and comply with NICE recommendations. It is important that patients can be guaranteed access to appropriate and cost-effective drugs irrespective of whether a service is commissioned by the NHS or by local authorities. That is what this amendment aims to do. I beg to move.
My Lords, I should declare an interest as honorary vice-president of the Local Government Association. I congratulate the noble Lord, Lord Ribeiro, on closing a lacuna and promoting integration, which has been a strong theme of our debates. He has spotted a difficulty and has dealt with it extremely competently. I trust that the Minister will be able to accept the amendment, which makes great sense and should contribute to the fulfilment of local authorities’ obligations in this sphere.
My Lords, I am grateful to my noble friend Lord Ribeiro for tabling these amendments, which address the important issue of ensuring that patients have consistent access to appropriate and cost-effective drugs, whether a service is commissioned by the NHS or by local authorities.
As the House will know, NICE’s technology appraisals provide important recommendations on the clinical and cost-effective use of medicines and other technologies in the NHS. The funding direction that applies to recommendations in NICE technology appraisals has helped to ensure equity of access to NICE-recommended drugs and treatments wherever patients live in England.
While technology appraisals are perhaps most commonly associated with specialist drugs or interventions used or initiated in NHS secondary care, they also make important recommendations about drugs and interventions for use in other care settings, including preventive interventions. In future, these are likely to fall within the scope of local authority commissioning responsibilities for public health. My noble friend mentioned the example of Champix. He is right: technology appraisals could address drugs to aid smoking cessation and treatments to tackle substance misuse.
I agree with my noble friend that extending a funding mandate to NICE-appraised drugs or treatments commissioned by local authorities would bring important benefits. It would guarantee patients access to appropriate and cost-effective drugs, whether a service was commissioned by the NHS or by local authorities. In doing so, it would protect patients’ existing rights as set out in the handbook to the NHS constitution, to which he rightly made reference. I am very pleased that I am able to support these amendments and I hope that your Lordships will feel able to support them as well.
Amendment 256 agreed.
Amendment 257 agreed.
Clause 244 : Failure by NICE to discharge any of its functions
258: Clause 244, page 239, line 29, at end insert—
“( ) For the purposes of this section, a failure to discharge a function properly includes a failure to discharge it consistently with what the Secretary of State considers to be the interests of the health service in England or (as the case may be) with what otherwise appears to the Secretary of State to be the purpose for which it is conferred.”
Amendment 258 agreed.