Amendment 83

Health and Care Bill - Committee (5th Day) – in the House of Lords at 6:00 pm on 24th January 2022.

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Baroness Walmsley:

Moved by Baroness Walmsley

83: Clause 20, page 17, line 25, at end insert “and to ensure the availability of sufficient well-trained staff to provide safe staffing levels.”Member’s explanatory statementThis amendment draws the attention of the integrated care board to the need to ensure sufficient well-trained staff to comply with safe staffing levels.

Photo of Baroness Walmsley Baroness Walmsley Co-Deputy Leader of the Liberal Democrat Peers

My Lords, in moving Amendment 83 in my name, I want to speak to Amendment 86, also in my name, and to support Amendments 146, 170 and 171.

Everybody taking part in these debates, including the Ministers, would acknowledge the central importance of the staff of the NHS and social care, at every level, and their training, well-being and retention. However, it was clear from the evidence on the workforce to the committee and in debates in the House in another place that there is broad concern that planning for the provision of sufficient of the right staff in all areas has not been good enough. Given how long it takes to train a doctor, an allied health professional or a nurse, excellent forward planning is essential. Proposals were made in another place to improve that in the future but, unfortunately, the Government would accept only a mandated review every five years. This group of amendments is this House’s opportunity to try again, and I hope the Minister will be able to help us.

These amendments show that, in the opinion of noble Lords, the planning of health, public health and care staff must be based on an accurate, independently verified understanding of both the current situation and, as well as can be predicted, future need. Because the political responsibility lies with the Secretary of State, this information collection and planning must exist at the very top, as well as at NHS England and the ICS commissioning level. Clause 35 refers only to the workforce needs of health services, but Amendment 170 lays down detail on what the Secretary of State must do to fulfil this responsibility, not just for health but for public health and social care, since they are so interlinked. We look forward to the White Paper and legislation on social care and hope that workforce issues will be well covered in them, but we need to address it now, in this Bill, even though it would have been better to hear the Government’s proposals on social care first. Amendment 146 says what must be done at ICS level. Crucially, both amendments require appropriate consultation. But there is something I would like to add, and that is where my Amendments 83 and 86 come in.

Every hospital trust and primary care setting has done the work to identify and agree the safe staffing levels of each type and seniority of staff in each setting. This is based on an understanding of the local context and of the knowledge and skills needed for patient safety to deliver each treatment, and an assessment of how many patients can safely be looked after by each member of staff. This varies enormously from setting to setting—from a whole team of staff to each patient in operating theatres, to one-to-one in ICUs and premature baby units, and to several patients to one member of staff in less acute areas.

During the pandemic, we have seen these levels necessarily abandoned, with, for example, one ICU nurse being asked to care for two or even three patients at the peak. This has been an unusual crisis situation and services have had to be flexible, moving staff from one department to another, always, I hope, under the supervision of a staff member with the correct speciality. Hospitals have helped each other and ambulances have been diverted when no bed could be found for patients coming into A&E. That has been the advantage of having a National Health Service.

It has been very difficult for staff, and many have quit their jobs. We started the pandemic with tens of thousands of doctor and nurse vacancies, and the BMA has calculated that we currently have a shortfall of 50,000 full-time equivalent doctors—more than the number of unfilled posts. Our doctor-patient ratio is 25 years behind that of similar OECD countries. In the UK, before the pandemic, there was already a shortage of around 50,000 nurses, and still the healthcare system is nowhere near bridging that gap. In December 2020, a report by the Health Foundation, Building the NHS Nursing Workforce in England, said that the Government will need to exceed their target of 50,000 new nurses in England by 2024-25 if they want the NHS to fully recover from the coronavirus pandemic.

In January 2021, a survey by Nursing Times indicated that 80% of nurses feel that patient safety is being compromised due to this severe staff shortage, which is why my amendments focus on safe staffing levels. While there has been a good increase in the number of nursing students starting courses during 2020, this will not alleviate the issue of a lack of qualified nurses now or in the medium term. There are particular shortages among mental health and cancer support nurses. Cancer Research has also told us that one in 10 cancer diagnostic posts in England is vacant, which threatens the Government’s cancer target. There are also considerable shortages in other allied professions.

We have also seen a reduction in the number of in-patient beds in the last 10 years and bed occupancy rates well in excess of the recommended percentage. Even before the pandemic, some hospitals had no available beds at all during the winter period, leading to nearly every winter period being labelled a crisis. All this is because of the perennial failure to train enough staff.

Despite the increased use of technology, health and care continue to be people businesses, but there has not been enough effective planning to provide the workforce needed, not just for normal services but to provide the resilience needed for the winter and for future pandemics. This has partly been due to “leaky bucket” syndrome—the failure to retain staff because of the pressure and, in some cases, pay or pension issues. That must change. Health Education England is now to be incorporated into NHS England, and the Bill and the forthcoming social care legislation are opportunities to start again. We have one and a half million care workers, with high turnover. In order to improve retention, good training and a career path are needed.

I turn, however, to the detail of my amendments. Included in the duties of the new ICBs is, as set out in Clause 20, in new Section 14Z41, a duty to promote education and training. My Amendment 83 adds to that duty that it should train enough of the right staff to reach safe staffing levels in all areas. My Amendment 86 adds to new Section 14Z42, which covers the duty to promote integration, a duty to improve the ability of NHS and care staff to carry out their duties within safe staffing levels.

The latter amendment recognises the risk to staff themselves as well as patients when they are forced to work with fewer than the prescribed safe number of colleagues, or to extend their shift by many hours because there is nobody to take over. It is a risk to their physical and mental health and it certainly does not help the ability of student nurses and doctors to learn from their senior colleagues when they do not have enough time to breathe. It also causes burnout, leading to significant numbers of doctors and nurses considering leaving the profession or reducing their hours. Some 32% of respondents to the BMA’s April 2021 Covid-19 tracker survey said that they were now more likely to take early retirement, while half reported being more likely to reduce their hours.

I believe that safe staffing levels are part of the duty of care that employers owe to their employees in the health service. However, the Nuffield Trust, Health Foundation and King’s Fund have estimated that, by 2030, the gap between supply of and demand for staff employed by NHS providers in England could reach almost 350,000 full-time equivalent posts if nothing is done. Worryingly, that was based on pre-pandemic calculations. Overcoming unsafe staffing levels is an essential measure to ensure patient safety and to boost the well-being, morale and productivity of staff and, therefore, their retention. The Bill is an opportunity for the Government to take sustainable action to alleviate issues relating to workforce supply and demand in England.

The duties proposed in Amendments 146, 170 and 171 would be welcome, and I support them, but they are not enough. I think that safe staffing should be specifically mentioned among the duties of the ICB, and that is where my amendments would put it. I beg to move.

Photo of Lord McNicol of West Kilbride Lord McNicol of West Kilbride Deputy Chairman of Committees

My Lords, we have two noble Baronesses taking part remotely. I first call the noble Baroness, Lady Brinton.

Photo of Baroness Brinton Baroness Brinton Liberal Democrat Lords Spokesperson (Health)

My Lords, the present Health Minister and his predecessors for a number of years—far too many years, frankly—should not be surprised by these amendments, all of which cover the issue of workforce planning. Often, Ministers’ words and aspirations have been supportive but the reality is that, without proper long-term workforce planning, the NHS and our social care sectors will struggle to be able to plan for the medium term, let alone the short term.

My noble friend Lady Walmsley introduced this group by saying what is needed in workforce planning and why, and I support her brief but critical amendment to ensure patient safety. The other amendments in this group set out the how: whether the workforce planning reports or clinical and healthcare training needs in Amendment 171, the duty on the Secretary of State in Amendment 173, the report on parity of pay in Amendment 174 or the important Amendment 214 from the noble Baroness, Lady Finlay, on workforce boards. I am looking forward to hearing the expert contributions to follow on them from the noble Lord, Lord Stevens, and many other noble Lords, and I hope that the Minister will take note of how the lack of effective workforce planning is hobbling the provision of health and care services in England.

I will focus on Amendment 170 from the noble Baroness, Lady Cumberlege, which I have signed, which sets out the reporting structures for appropriate long-term planning, addressing future workforce supply over the next five, 10 and 20 years, along with who should be consulted and, importantly, that independent assessors should confirm that the data used is correct. We need to remember that, in the election in 2019, the Prime Minister promised 6,000 more GPs by 2024 and, before him, his predecessor Theresa May had promised an extra 5,000 GPs by 2020. Both were setting themselves up to fail, because it takes five to seven years to recruit and train a GP and another two or three years to provide the extra staff on clinical undergraduate and postgraduate courses to teach them. It is worth noting that the full-time equivalent number of GPs in 2015 was 42,961, which had dropped—not increased—to 35,991 last year. That is a drop of around 15%, and evidence of the burnout and drop-out that my noble friend Lady Walmsley referred to earlier.

Workforce planning must look beyond the traditional doctor and nurse workforce numbers that appear in election manifestos. We know that our healthcare practices are changing, with nurse practitioners, specialist physios, occupational therapists, radiographers and many others all picking up tasks formerly carried out by doctors. With in-patient stays reducing in time thanks to advances in surgery and new treatments, our health and social care system needs to develop new pathways in community deliveries. Without a specialist workforce plan for community deliveries, it will also fail.

The fundamental problem here is, I presume, the cost of clinical courses. Ministers have chosen in the past to rely on bringing qualified healthcare staff in from abroad, especially from low and middle-income countries. This is morally wrong. I am really grateful for the correspondence from Professor Rachel Jenkins, who rightly reminds us why the NHS’s constant use of clinicians and healthcare professionals from lower and middle-income countries, rather than increasing the university and training places for our own home-grown health professionals, is so damaging:

“The heart of the problem is the sheer scale of loss of health staff from low and middle income countries (LMIC) to high income countries, especially to the UK, which has 30% of its doctors recruited from and trained by low and middle income countries, approaching double the OECD average of recruitment from LMIC, and with the situation escalating fast.”

Around 20 years ago, when I was a trustee of Christian Blind Mission, a global disability charity, I saw the consequences of this in practice. CBM worked with the exceptional surgeon Steve Mannion, who provides innovative club-foot surgery and treatment and trains Malawian medical students and doctors in his ground-breaking surgical practices. In 2003, along with local surgeons across Africa, he helped to set up COSECSA, a surgical college to cover central, eastern and southern Africa. He did this because, as he said in 2003, he was the only orthopaedic surgeon for the central and northern regions of Malawi, a catchment population of 6 million to 7 million people. He was clear that this was caused by countries like the UK offering attractive posts in our hospitals, which had catastrophic consequences on medical services in their own countries. In 2003, there were more Malawian surgeons in Manchester than in Malawi.

Because of the lack of workforce planning and funding in place to train those needed for our NHS, many of our hospitals have had to rely on this willing, responsible and committed cohort of professionals from across the world. We are still depriving Africa of surgeons and countries such as the Philippines of nurses, and it is not good enough. My local hospital, Watford General, has a good scheme by which nurses from the Philippines come for a specific time only, and return home with not just experience but further qualifications under their belts.

There is a place for this type of arrangement, but it must not be at the cost of draining the skills from lower-income and middle-income countries and should not be a replacement for the responsibility we bear to ensure that we have the ability to train our own local workforce. I am really grateful to Professor Jenkins for her timely letter. She also pointed out that the ratios of doctors and nurses in lower-income and middle-income countries are still sometimes a third of the numbers we have in more developed countries.

I return to the principles behind the amendments in this group. The lack of proper and effective long-term workforce planning exacerbates many of the problems in our NHS and social care sector. This Bill and these amendments give us the right number of staff that we need to be able to do this, but, without any workforce planning, it will be entirely hit and miss. We need resilience. We cannot continue to lose staff because of the pressure we are putting them under. We must not have a service that becomes unsafe because staff step up to do extra shifts, over and above, when they are extremely tired.

We have to have clear career pathways linked to workforce planning, not just in the NHS but in social care. We cannot have the position we have at the moment, where social care is being denuded of nurses because they are all going to the NHS, which can offer them more pay. Above all, we need a key tool for the design, funding and delivery of health and care services in England in future. These amendments, especially Amendment 170, set out how we can do that. I look forward to the Minister’s response.

Photo of Lord McNicol of West Kilbride Lord McNicol of West Kilbride Deputy Chairman of Committees 6:15 pm, 24th January 2022

My Lords, we have one more noble Baroness taking part remotely. I invite the noble Baroness, Lady Masham of Ilton, to make her comments.

Photo of Baroness Masham of Ilton Baroness Masham of Ilton Crossbench

My Lords, I am very supportive of this group of amendments. There cannot be a safe, effective National Health Service without an adequate, well-trained workforce in hospitals, in care homes and for people who need care in their own homes, as well as adequate GPs and community staff.

At this time, it is more difficult than ever to recruit, as so many nurses and carers left to go back to Europe and the world has been struck by the coronavirus. Many people are off sick with the virus or isolating, and some are tired with stress and overwork. It is not helped when the relations and partners of patients have not been allowed in to help disabled and elderly patients in hospitals. They can help with feeding and giving patients extra help and support, which staff do not have the time to do.

The Royal College of Nursing says that the Bill gives

“no assurance that the system is recruiting and training enough staff to sustainably deliver health and care services.”

As has been said, there should be forward planning for the workforce. For example, the biggest barrier to improving early diagnosis of bowel cancer is long-standing staff shortages in endoscopy, pathology services and gastroenterology, with 43% of advertised posts not being filled. This is really serious. With so many posts across the country not being filled, a variety of specialties are so badly needed. There must be more training opportunities. Without adequate training, there will be no hope of filling the unfilled posts.

It would be very welcome if the Government brought some amendments on Report to help make the recruitment of staff, who are so desperately needed, more successful. Without enough staff, all the important things your Lordships have been discussing today, such as innovation and research, will be unachievable. A thriving workforce is absolutely essential.

Photo of Lord Lea of Crondall Lord Lea of Crondall Non-affiliated

My Lords, manpower planning requires a bit of definition. In my role at the TUC over many years, one of my functions was to look after all the sectoral committees. The most assiduously attended was the health services committee. As we all know, there is an enormous number of specialities in the health service.

When it comes to manpower planning, why did people not press the right button? I am afraid that there is no button to press. In 1947 Aneurin Bevan found that with the British Medical Association there was no wish or desire on the part of the doctors to be part of a structure where a button could be pressed—as might be true in a great corporation—to make sure that the plan for manpower was implemented. As we all know—I will be corrected by someone in this Committee if I have got it wrong—GPs are not appointed by the National Health Service in the way you would appoint somebody to be in charge of an oil refinery in the oil industry or whatever.

It would be useful if the Minister—and I have given notice of a question along these lines—could say what the subjects of the workforce strategy in the Bill would be. How would it be funded? What would be the timescale for introducing it? How often would it be updated? The analysis would have to include such questions as reliance on locums; anecdotally, they can prove very expensive. Will there be targets and associated timescales for the reductions in vacancies?

All of this is easier said than done. I think the remark can legitimately be made that money does not grow on trees, so how are we going to proceed on this? I do not think that everybody who advocates manpower planning is totally naive. Jeremy Hunt in the other place advocated something very much along the lines of what we are talking about now. The focus of the question was on whether five years, 10 years or some other number of years was far too long. There should be reviews every two years or on some shorter timescale.

I confess that, if I were the Minister, I would say, “You’re begging the question of whether we know what we’re talking about when we talk about manpower planning”. So I would be glad if the Minister, in giving some thought to this debate, would care to write to noble Lords—not a White Paper or anything like that—to answer specifically how this thing would work. It is an excellent initiative, and I very much welcome the fact that there is a clause in the Bill providing for this manpower planning.

Edward Argar, for the Government, said that substantial work was ongoing, and referred to a 15-year strategic framework for the health and social care workforce, so the beginnings of creative thinking in this area have gone some way. I congratulate the Government on that. I am afraid, however, that until we get Ministers to be a bit more explicit about what we are talking about, and how the workforce plan will work, this will be a missed opportunity.

In conclusion, I acknowledge that there are a number of sacred cows in this area—and unfortunately, many of those sacred cows are incompatible with each other. It would be useful if the Minister acknowledged that we are asking the right questions. That, obviously, is the necessary precondition to finding the right answers.

Photo of Baroness Cumberlege Baroness Cumberlege Conservative 6:30 pm, 24th January 2022

My Lords, I shall speak to Amendment 170, in my name. I thank the noble Lord, Lord Stevens of Birmingham, who supported my amendment, the noble Lord, Lord Hunt of Kings Heath—I do not know whether he is coming back—and the noble Baroness, Lady Brinton, who has already spoken. I thank the noble Baroness for speaking to the amendments in her usual comprehensive and thorough way. It was interesting that she talked about Malawi and the Philippines, and the issue of local training, which is so important.

We have all applauded health and care workers, both on our own doorsteps and when we meet them, on or off their job. Omicron has put them under huge pressure yet again, but despite that—despite isolating or testing positive—we know that they will cope. The NHS will cope.

The NHS is a public service, which means the service works for the people. That is its sole purpose. To achieve that, normal service must resume as soon as possible. The public have been understanding: they understand that there is a crisis, and that normal service cannot be delivered right now. There can be no doubt that Covid and its variants are a crisis for health and care. But Covid is a crisis atop another crisis, a deeper malignancy, which constrains and threatens the NHS—and, of course, the care sector; we must think of the two together—with or without Covid. I speak of the workforce crisis, now considered by experts, and by people in the service and outside it, the single greatest problem that the service now faces.

Numbers can be used to make any argument stand up, even a spurious one. But in the case of our health and care workforce crisis, the numbers are real, stark and heading in the wrong direction. Two years ago, before the pandemic, the average number of vacancies in adult social care was 112,000; the average number of vacancies in the NHS was 101,000. It is no secret that Covid is making a very bad situation worse. Internal NHS figures showing total absences across acute, mental health and community trusts nationally hit almost 120,000 on Wednesday 5 January. NHS staff absence figures are published weekly over the winter. The reported figure for staff absences, published last Thursday, 13 January, show that a weekly average of almost 89,000 hospital staff in England were absent, with the highest one-day peak for this winter being over 94,000. This is piling pressure upon pressure.

That tells us that we have a serious problem here and now—and, as the noble Baronesses, Lady Masham and Lady Brinton, said, it takes a long time to train skilled health and care staff. We need to act now if we want to feel the benefit in future. According to the Royal College of Physicians, nearly 48%—nearly half—of advertised consultant posts went unfilled in 2020, mostly due, sadly, to a lack of any applicants. The noble Baroness, Lady Finlay, mentioned this in a previous debate.

There are nearly 40,000 full-time equivalent nurse vacancies in the NHS in England. That is a vacancy rate of more than 10%. The Royal College of Nursing expects 52,000 nurses to retire in the next few years. Nearly 7% of roles in adult social care were vacant in 2020-21. It is estimated that we are 50,000 doctors short, and in total the Health Foundation says we need 488,000 more healthcare staff in the next decade. I apologise for flinging so many figures at your Lordships, but they underline a simple yet serious problem—and if we do not have credible, reliable, up-to-date numbers, how can we plan?

The health and care sector urgently needs better workforce planning. We need to know how much slack is in the system, and how it can cope not only with the expected but with the unexpected. We know from the experience of the last two years that the unexpected can, and so often does, happen.

Behind all those numbers are real people—professionals working flat out every day and every night to keep the show on the road, to care for patients and to keep them safe. I think we all agree that they are doing a valiant job, trying to be professional and compassionate, often in desperately difficult circumstances. But there is only so much that people can do when their team is not at full strength.

I am the first to admit that my amendment will not solve the workforce crisis. It will, however, provide the NHS and the care sector with a regular accurate national picture of the numbers of staff needed now and in future to meet demand. It will be publicly available, so we will all be able to see what is needed. It will provide a strong and much-needed foundation on which to take decisions about funding, skill mix, regional shortfalls and shortages of specialists. It will be published every two years. I think published annual assessments are too frequent. Two years is a reasonable interval: say, twice in the average time between general elections—one to say the last Government got it all wrong, and one to put it all to rights.

We could, of course, carry on as we are, without the information, a proper strategy or the ability to plan for the future—travelling in hope rather than expectation. That is not working. We already know that; the dozens of outside organisations which support this amendment— from royal colleges and professional bodies to charities and think tanks—know that; and, most importantly, the public know that, because they can see the pressure that NHS and care sector staff are under. To carry on like this would be to condemn our care services to flying blind through a storm. This amendment gives us the ability to set and navigate a sustainable course. With the extraordinary consensus behind this amendment and the impressive cross-party support we have had throughout Westminster, one would hope that it will find favour in your Lordships’ House and with the Government.

I listened carefully to the debate on a similar amendment in another place. The main argument Ministers made then was that the planned update to Health Education England’s 15-year strategic framework for workforce planning, known as framework 15, would do the job instead. I beg to differ, as do the 88 organisations which support this amendment. Previous versions of framework 15 have not quantified the workforce numbers, and the Government have been unable to confirm that the revised framework will set out the required numbers of staff. Even if the updated framework 15 had included projections of future needs—it did not—it would only be a one-off, and there would be no requirement regularly to update these predictions.

Might there be a concern about the financial implications of enacting this amendment? Do some worry that it may herald an increase in health and care staffing costs? I hope not, because to reject this amendment on those grounds would be a false economy. The NHS alone spends vast sums on agency staff, one of the most expensive and least satisfactory ways to manage an endemic workforce problem. The latest number I could find was for 2019-20, when the NHS in England spent an eye-watering £6.2 billion on agency staff, which was an increase on the previous two years. This amendment paves the way for reducing those expensive sticking-plaster solutions in favour of something sustainable and more cost effective.

There are, of course, many hurdles to overcome if we are to improve workforce planning and capacity management. There are issues that far greater brains than mine need to think about—the rise of AI, for example. In my household, married as I am to a farmer, as Members will know, AI has quite a different meaning. I am not referring to artificial insemination, but rather to artificial intelligence. What impact will that have on workforce planning and staffing? What about the rising trend of part-time work, telehealth or changes to skill mix? Those are all good questions that these clever brains stand a far better chance of answering if they have alongside them the regular, credible, national picture that this amendment seeks to provide.

In my view, we owe it to the staff working in health and care, and to the public who rely on them, to do better, to plan better, to prepare for the future and to ensure that the NHS and the care sector are at full strength. This amendment points us in that direction, and I hope the noble Lords here to answer the debate today will work with their colleagues in government to see the value—the worth—of this very simple amendment.

Photo of Lord Stevens of Birmingham Lord Stevens of Birmingham Crossbench 6:45 pm, 24th January 2022

My Lords, in theory these amendments should not be needed, but in practice they clearly are, as the noble Baroness, Lady Cumberlege, has just so forensically set out. It is a statement of the blindingly obvious, particularly coming out of the pandemic, to say that we need better workforce planning at a time when staff are exhausted from having dealt with Covid for several years and the NHS is confronting the need to deal with the backlog of care.

But, frankly, it would be a statement of the blindingly obvious at any time, because the lead times for decisions on training for health professionals are such that they go beyond any individual term of Parliament or government manifesto. Universities need a strong signal as to what future demand will look like. The interconnectedness between health and social care means that we are actually thinking about a workforce of 3 million plus, and the materiality of getting it wrong over a five or 10-year period is bigger in this sector of the workforce than any other part of the economy. As we heard earlier—I think from the noble Baroness, Lady Walmsley—estimates from the Health Foundation, for example, suggest that on the current trajectory the gap could be more than a third of a million staff in the health service by 2030-31; and in respect of the social care workforce, Skills for Care talks about perhaps 490,000 additional posts being required over the period to 2035. Those figures may be right or they may be wrong, but there is not a forensic forum in which those debates are scrutinised and choices made. This is not just about more; this is about different.

It is not all doom and gloom. Over the last two years, during the most intense challenge the health service has faced since its creation, nearly 160,000 people have signed up to join the health and care staff and professions. We have seen applications for undergraduate nursing up by more than a quarter and a huge increase in applications for and interest in studying medicine, yet we have an acceptance rate of only about 52% for undergraduate nursing, according to figures from UCAS, and we are turning away bright and brilliant young people with fantastic A-level grades who would like to study medicine. That is a paradox which stems from the fact that, unlike the day-to-day running costs of the health service, those items which have the longest planning horizon—workforce and capital investment—are the areas with the shortest financial horizon.

Of course, it may well be argued by the Government that we are about to turn a corner and that although there has been a degree of short-termism hitherto, things are about to improve. But I am afraid that I think we are entitled to treat that proposition with a degree of scepticism, because although what has been said up until now may be blindingly obvious, in fact what we have been confronted with is wilful blindness. Health Education England, which should be looking at 10 years, does not yet have its running budget for 10 weeks’ time. If we look back over the history of recent years, we can see a series of missed opportunities. The Minister may assure us that we will be presented with this 15-year further vision from Health Education England this coming summer, which will, of course, be welcome. But if we remind ourselves of the history since 2014 or 2015, as I say, we can perhaps be a tad sceptical. Obviously, I draw attention to my prior NHS interest, and everything I am about to say only draws on the public record, just to clarify that point.

It was back in 2014 that the NHS Five Year Forward View talked about the service changes that were required, but it was not permitted to talk about future capital investment, social care or workforce training, since they were being kept separate. So, in summer 2016, the Department of Health and Social Care was going to produce this detailed quantified workforce plan instead. Twenty-sixteen came and went and instead, in December 2017—three years after the Five Year Forward View—Health Education England launched a consultation document which said: “Your responses will be used to inform the full strategy to be published in July 2018 to coincide with the NHS’s 70th birthday.”

Twenty-eighteen came and went, and answers saw we none. Then in June 2019, we got another, in this case interim people plan, with lots of excellent content but unfortunately no actual numbers and no new pound notes. Despite the fact that it promised:

“We will aim to publish a full, costed five-year Plan later this year” quantifying

“the full range of additional staff needed”.

But again, “later this year” came and went, and no such documents saw the light of day, until in July 2020 we had a one-year people plan which, at that point, was covering just the next eight months. Fear not, though, because it said:

“Further action for 2021/22 and beyond is expected to be set out later in the year”— in 2020—

“once funding arrangements have been confirmed by the Government.”

That did not happen.

Instead, in July 2021, last summer, the Department of Health and Social Care again commissioned Health Education England to start from scratch. Last November, HEE published a short PowerPoint—commissioned from a firm of accountants—with the discouraging disclaimer on the first page that:

“We do not warrant or represent that the report is appropriate for your purposes” and “no warranty is made as to the accuracy of any data”. As it happens, that does not really matter because there were no real data in the document anyway, which came to startling conclusions such as “workforce demand will be affected by demography and disease”.

I think we are entitled to say that this litany tells us that what, to everybody else, is blindingly obvious has instead been confronted with wilful blindness. What explains this? Is it a lack of interest on the part of the committed people to getting this right? No, it is not—some excellent work has been done. Your Lordships may take a clue from a statement that Jeremy Hunt, the former Secretary of State and now Chair of the Commons Health and Social Care Committee, made last Tuesday, when he said that “the Health and Social Care Committee has recommended on numerous occasions that we should have independently verified forecasts of the number of doctors, nurses and other staff that we should be training for the future. But that has been blocked consistently by the Treasury”.

Without in any way commenting on or editorialising that, the Minister may want to take the opportunity to confirm whether that is indeed the case. But just on the off chance that he does not refute the statement Jeremy Hunt has made, then that, I think, tells us that unfortunately, these amendments are necessary and will strengthen the hand of Health and Social Care Ministers in the future. I cannot help thinking that, in their heart of hearts, past Health Ministers know that they would have benefited enormously, were these amendments on the statute book. I am afraid that, if the Government choose not to support these amendments—as I hope will not be the case—that will be proof positive that they are very necessary. Therefore, I hope they will recognise that ignorance is not bliss and if we do find ourselves in that situation, this House will take the opportunity at Report to give the Commons another go.

Photo of Lord Patel Lord Patel Crossbench

My Lords, listening to my noble friend Lord Stevens of Birmingham, I am beginning to feel the pain of his frustration at being chief executive of the NHS and not being listened to in order to fix such an important issue as workforce planning. Also, there is a bit of déjà vu that he may remember, along with some of my colleagues who were took part in the Lords committee inquiry into the long-term sustainability of the NHS and adult social care.

Let me argue the same issues that he just presented. The report on the long-term sustainability of the NHS and adult social care, published in April 2017, looked at data on demographic and disease burden projections of the population over the next 15 to 20 years. It identified a lack of long-term workforce planning as a key threat to the long-term sustainability of the NHS. The Committee heard from the then Secretary of State, the right honourable Jeremy Hunt, who had this to say:

“workforce planning is an area where we have failed… Brexit will be a catalyst to get this right… That is an area where we need to be much more strategic”.

That was nearly five years ago and yet, there is no strategic healthcare workforce plan from the Department of Health and Social Care, as we just heard.

The solution is not going to come from an outside body, no matter how influential. It has to come from the centre, from the leadership of the NHS and social care, and not one in the isolation from the other. What we have heard from the centre and NHS organisations is many publications identifying the problem, but not the solution with a long-term plan. We are told that this may be coming in April 2022—or perhaps later.

On the other hand, there are several detailed authoritative documents on the NHS workforce from think tanks, NHS providers, the BMA, the nursing councils and many others, who have been grappling with this issue and trying to find a solution for a long time and advising the Government on how to do this. There is no lack of authoritative reports based on data related to long-term projections of population, its demography, health needs and the workforce needed to deliver them. For example, an extensive, well-researched report by Dr Latifa Patel, a respiratory paediatrician, and Dr Wrigley, a GP of medical staff in England, projected to 2045—based on population and disease data—the number of doctors needed in each speciality and possible models of plans to deliver on this by 2032. A document extending to 60 pages is not only highly informative and well-researched but identifies a way forward.

Since the Health and Social Care Act 2012, there has been inadequate workforce planning, fuelled by inadequate regional and national workforce data and a lack of accountability for it at government level. We are not training enough doctors, despite record numbers of people applying. The latest figures, as the noble Lord, Lord Stevens of Birmingham, mentioned, show a 21% increase on previous years in applications to medical schools of highly talented young people. This means the NHS is ill-equipped to tackle the backlog of care, is not prepared for future public health crises and cannot meet patient needs, either now or in the future.

If we compare England with EU nations within the OECD, which have an average of 3.7 doctors per 1,000 people, the medical workforce in England is currently short of around 49,000 full-time equivalent doctors. Without significant intervention regarding the current rate of growth, the estimate is that the future medical workforce shortage will be between 26,889 and 83,779 full-time doctors by 2043. Such precise numbers show how well-researched this document is. Each full-time doctor in NHS England is doing an average of 1.3 full-time equivalent roles. I have three of them in the NHS and I can see what they do—although I tell them they are lazy compared to me.

The NHS faces a huge backlog of care, post pandemic. Estimates are that there were 3.37 million fewer elective procedures and 21.4 million fewer out-patient attendances between April 2020 and March 2021. On top of this, the population is expected to grow around 9% over the next 25 years to more than 61.5 million. At least one in four adults will be aged 65 or over, and the number of people aged 85 or older will have nearly doubled to 3 million by 2043.

Staff retention is poor and is set to worsen without intervention. This is caused largely by the vicious cycle of medical workforce shortages, overworking existing staff, years of demoralising pay erosions and punitive pension taxation rules. We have 1,307 fewer qualified full-time-equivalent GPs now than in September 2015, while shortages of specialist occupational physicians and public health doctors are severely impacting efforts to keep the population healthy. The shortage of medical academics means that training the next generation of doctors has become even harder. You do not just get medical or nursing graduates by increasing the intake: you have to provide the resources—manpower, equipment and capital funding—to train them. In the last 10 years, the senior clinical academic workforce reduced by 27%, while the number of medical students grew by more than 25%. For those of us who have trained medical students and postgraduates for years, medical undergraduate training committed at least two sessions a week from each one of us—that is one day—apart from undertaking extra duties. Not a single region in the country meets the current OECD EU country average of 3.7 doctors per 1,000 people.

The medical workforce itself is ageing, meaning that we risk losing around 16,818 secondary and 8,676 primary care doctors—a total of up to 25,494—in the next 10 years due to natural retirement. One in five doctors is saying that they will leave their career in the NHS altogether post pandemic. I repeat: one in five. This figure might be as high as 31,820 doctors. Those noble Lords who have not seen the recent report by the GMC might like to look at it, because it confirms these findings. Other health services carry a significant number of vacancies, but, even if all currently known vacant medical posts were filled tomorrow, we would still need 42,528 more full-time-equivalent doctors and doctors in training to meet the OECD EU country average of 3.7 doctors per 1,000 people in England.

International medical graduates have always been, and will remain, a key part of our medical workforce. However, international recruitment must not come at the expense of developing countries, so a sustainable, long-term workforce strategy is needed. While there is increasing multidisciplinary working within healthcare services, while there will be technological advances, and while non-medical roles have expanded in recent years, the doctors’ unique skill set is essential.

The report by Patel and Wrigley also makes estimates of cost based on data, along with reports from the Health Foundation and the Institute of Fiscal Studies report of 2018. To meet the current shortfall in the medical workforce by 2030 and increase training slots would require in the region of about £8 billion over the next three years. That is not so much when you consider, as the noble Baroness, Lady Cumberlege, indicated, that we are spending £6 billion on locum or agency fees.

I have spoken about the medical workforce, but I absolutely accept that similar problems—and perhaps even worse—need addressing in nursing and other healthcare professional workforces. I have no doubt that my noble friend Lady Watkins of Tavistock might well address that issue. I make a case for an urgent need—not in two years or three years or four years—for a strategy on health and social care workforce planning from the Department of Health and Social Care. The amendments in the name of the noble Baroness, Lady Merron, do this, and I have added my name to her two amendments. They put a duty on Health Education England to do this, and a further duty on the Secretary of State to report annually to Parliament, not only on the workforce plans but on the funding to support the plans.

There is only one thing that I would add, if the noble Baroness would accept it, and that is for the House of Commons Health and Social Care Committee to have an independent expert analysis carried out every two years on the delivery of government policy commitments on the health service workforce. An example of such an exercise is the one that the committee carried out establishing an expert panel that reported on mental health services and identified the gaps in the delivery of policy commitments in mental health. I strongly support the noble Baroness’s amendments.

Photo of Baroness Verma Baroness Verma Chair, EU Goods Sub-Committee, Chair, EU Goods Sub-Committee 7:00 pm, 24th January 2022

My Lords, I declare my interest in the register. I am making a very short intervention just to talk about care workers. While there has been a great emphasis on the NHS, the crisis that the care sector is facing now is absolutely devastating. I was with care managers this morning, and they were wondering how they were going to manage the next few weeks, never mind the next few years. I urge the Government to understand that it is not just about added training and it is certainly not about planning for the future when the crisis is now. The crisis in the future cannot actually be estimated now, because we are in a crisis now.

So I urge the Government to look at the key issue around the sectors, and that is money. It is funding. We devalue the very people we expect to have value for in looking after the elderly, the disabled and those who need help. I came here not wanting to intervene today, but I was actually pushed by what I saw this morning with my care managers. They are absolutely struggling, trying to work out where they are going to find these magical beings who do not exist, because they have left the sector as a result of being so poorly paid, so badly treated and so deeply undervalued by everyone. I just wanted to put that intervention on record because, while we do need workforce planning, the problem is that we are so far behind the curve that it is going to take one mighty big plan to get this right.

Photo of Baroness Hollins Baroness Hollins Crossbench

My Lords, I would like to follow the noble Baroness because my amendment relates to this issue. My Amendment 174 would require the Secretary of State to publish a report on the work undertaken to bring parity of pay between health and social care services.

When reflecting on the pandemic, it is clear that we owe an enormous debt of gratitude to our key workers, who went above and beyond the call of duty to keep people safe and healthy. Their efforts resulted in a deserved pay rise for NHS front-line staff. However, it highlighted the disparity between the treatment of healthcare staff and social care staff. While we clapped for both every Thursday, the gap in pay and reward between the two professions has grown even larger. This amendment reflects the undeniable need to see care staff recognised equally alongside NHS staff.

The social care workforce is, and needs to be, highly skilled. It holds a heavy weight of responsibility for the well-being and safety of vulnerable adults and children. Staff are trained to support medication, undertake PEG feeding, deal with seizures and administer first aid. They help people manage their finances, health and well-being, and they provide emotional support. They operate within a highly regulated sector, necessitating an understanding of health and safety, mental capacity and deprivation of liberty law, safeguarding and even how to positively manage challenging behaviour. The importance of their role cannot be underestimated. Indeed, the same can be said for other, highly skilled allied health professionals, such as nurses and occupational therapists, whose breadth of interventions provide enormous value within the care sector, as well as within the NHS. The turnover rate is just so high. It is unsurprising that staff such as nurses and OTs who can do so are more likely to seek better paid employment in the NHS.

A report recently commissioned by Community Integrated Care shows that many front-line workers in social care are financially “significantly undervalued” by as much as 39%—nearly £7,000 a year—compared to equivalent publicly funded positions. Social care struggles to match pay conditions available within the health sector, including pensions, annual leave entitlements and sick pay. That means that, when faced with the choice of working in either sector, individuals are more likely choose to work in health, if they can. We must help foster a culture of collaboration between the NHS and social care.

Skills for Care estimates that the adult social care workforce in England employs over 1.5 million people, yet there remains a major recruitment and retention crisis which, without intervention, is only likely to get worse. Currently, there are over 100,000 vacancies—that is around 6.8%—with projections estimating that nearly 500,000 new jobs will be needed to meet demand within social care by 2035. The turnover rate of staff is estimated to be over 30%, and higher still among those on zero-hour contracts.

Pay is not a panacea for addressing this issue. Much of it comes down to better wages being offered in other sectors which are able to use market forces to drive up employee pay. Furthermore, if terms and conditions are more closely aligned between social care and the NHS, staff may be able to move more easily between sectors, providing the continuity of care for their patients in the community, which is so valued by so many people.

Social care has been defined as a low-paying industry by the Low Pay Commission every year since the first report of the Low Pay Commission on the national minimum wage in 1998. The average pay for support workers in England who assist people to live independently in the community is £17,695, or £9.05 per hour, which is 45p per hour below the real living wage—that is the average. It seems nonsensical for a single system to have staff working at similar levels but some being paid significantly less than others. The Government have previously argued that, because of the existence of private providers in the care market, they cannot mandate a level of pay for care staff. But this just does not hold up to scrutiny: providers are paid an hourly rate for the contracts they are given by the local authority. This means that there is a conduit through which a fair rate for providers, and by extension employees, could be set.

The continued insistence that an increase in the national living wage is suitable remuneration for care staff does not reflect the level of skill and dedication that they display. While this may reduce the barrier to entering the adult social care workforce, we are still left with problems retaining what will go on to become a much more experienced workforce. There is very little incentive to stay in terms of pay promotion, and the experience pay gap has reduced even more, to something like 1% per hour in the past year. We must address this issue to support this workforce, now and for the future.

Higher pay and lower vacancy rates have been associated with more favourable outcomes during inspections by the Care Quality Commission, which is not surprising. Put simply, a stronger and more valued workforce improves patient care and retention. The demand for the skills of the workforce, now and for the future, means that ensuring parity of pay and conditions between the health and social care sectors is of paramount importance in the care, rehabilitation and protection of people who need this support.

I thank Mencap for a very good brief, Skills for Care for excellent statistics, and my noble friend Lady Finlay for supporting my amendment. I hope that the Minister will see its value.

Photo of Baroness Watkins of Tavistock Baroness Watkins of Tavistock Deputy Chairman of Committees 7:15 pm, 24th January 2022

My Lords, it is a pleasure to follow the noble Baroness, Lady Hollins, and I completely support what she and the noble Baroness, Lady Verma, have just said. Unless care wages equate with the minimum for personal care in the NHS, we will never resolve this problem. I have been told by the National Care Forum that that means approximately £13.50 an hour. I would like to see that on the record.

The main reason I rise is in support of Amendments 173 and 171, which reflect other amendments looking at the need to ensure that we get workforce planning right for the future. Although we are talking about the future, we are also talking about the immediate crisis in social care.

I was amused at 6.36 pm to get a message from NHS Professionals, which said: “Dear Mary, you are receiving this email because you are registered on our NHS pathway for professionals. We still have many new opportunities that you would be interested in, so please feel free to log in and see now.” I do not know whether the noble Baroness, Lady Chisholm, who is just walking in now, has had the same email from NHS Professionals, but we both logged on at the same time—and she is nodding she has. We will stay here for the time being.

The pandemic has placed a spotlight on the health and care workforce and the pressures it sustained. However, these pressures are against a background of persistent under-recruitment, under-retention and under-representation. This shortfall has serious implications for patient and staff safety, as well as the efficiency of health and care services. In part, as others have said, this has been ameliorated by overseas recruitment. However, as a co-editor of the World Health Organization’s State of the World’s Nursing report last year, I have to say that that is not sustainable or ethical. However, I particularly congratulate the Chief Nursing Officer, Ruth May, for her initiative that enables and encourages refugees to register as nurses in this country, which is clearly an ethical practice.

A strategy to comprehensively monitor and meaningfully respond to the shortfall is essential to support the recovery and development of a strong, safe and sustainable workforce. As it stands, I do not believe that the Bill adequately mandates the actions required to achieve this ambition. As others have said, across the NHS there is a shortage of almost 100,000 full-time equivalent staff, with nursing staff accounting for 40% of vacancies in England. In the last five years, we have seen less than a 10% increase in mental health nursing staff and a continual decline in learning disability services. I understand there is an NHS England ambition for 21,000 new posts across the mental health system. This appetite for expansion—with the view that it translates to a sufficiently staffed and skilled workforce—is welcomed perhaps more so than ever, as 2.8 million people, or 5% of the population, had contact with secondary mental health, learning disability and autism services during 2020 and 2021.

As we are all aware, the workforce shortage is not limited to the NHS. The turnover rate of registered nurses in adult social care is four times higher than in the NHS, with marked regional differences. Getting the right number of staff with the right skills therefore remains a challenge and requires urgent review to maintain quality patient care. In care homes, the shortage of registered nurses has caused some providers to renounce their registration to provide nursing care, forcing some residents to find new homes. In hospitals, high staff turnover and the use of agency staff have contributed to excessive restrictions and blanket approaches to care for people with learning disabilities and autism, for example.

We have also seen an impact on growing waiting lists. In the first quarter of this year, only 61% of children and young people with eating disorders were seen within one week for urgent review—a 72% reduction from last year and falling below the national standard. I therefore welcome the focus on children and young people’s mental health teams, including the proposed approach to facilitate a much better system in schools. However, such healthcare workers will need to be included in workforce reviews to facilitate a system-wide understanding of current and projected needs and resources. We should celebrate that so many people want to become nurses and encourage them to do so by investing not only in university places but in apprenticeship schemes that enable a wide variety of people from different cultural backgrounds to enter the profession.

While workforce data is collected monthly and subject to validation, it is segregated by sector, which makes some comparisons difficult. There are also known data limitations. In social care, only half of the workforce is recorded; in general practice, sessional practice nursing is not directly comparable with the main workforce; and in the independent health sector there is no complete estimate of the total workforce, despite the fact that it provides significant NHS services.

All this necessitates an imperative call for a workforce strategy that goes beyond a five-year snapshot of the NHS. Rather, a collective effort across the health and care labour market, including community nursing and midwifery, is warranted to annually capture and forecast workforce shortages and requirements over time, with a five-year government strategic response and annual update. Without these amendments, England risks a future health and care workforce that lacks the sufficient capacity, competence and diversity that is necessary to achieve more integrated care and safely promote health and support the changing needs of the population.

Photo of The Bishop of London The Bishop of London Bishop

My Lords, I will speak briefly on Amendments 170, 171 and 173. As a former Chief Nursing Officer, I recognise the challenge of ensuring the right number with the right skills of those providing healthcare to meet the needs and the future needs of the population. As someone who, while the Government’s Chief Nursing Officer, was given the objective of finding 60,000 nurses, I understand that it requires a whole-systems approach. I often felt it was about science and art—the science was in the work that went on nationally but the art was in the way it was applied locally on the ground. The noble Baroness, Lady Walmsley, talked about how work on the ground is often not about intuition because that is about experience and knowledge; it is about how it is applied on the ground. I also reflect on the fact that although it was my role with all those working around me to find 60,000 nurses some years ago, we are seeking to find almost the same number today. That demonstrates the fact that we do not have a sustainable model of workforce planning and that we need to do better.

We have already heard how the Bill requires the Government to publish a report that describes the systems in place for assessing and meeting the needs of the workforce. We have already heard that that does not go far enough. In meeting workforce needs, systems are required for both planning and supply, but that does not ensure that it will happen. I believe that we need a system that has accountability, that puts into place long-term planning, and that is funded.

The Secretary of State needs to be held accountable for both workforce planning and supply, because there are some things that only the Secretary of State can do. For example, if the workforce planning systems are not co-ordinated at a national level, there is often limited ability to respond to local variations on the ground, such as those between rural and urban settings or between professions or sectors. For example, responding to local variations may require national changes, such as in training or registration.

There are also parts of the workforce planning system for which only the Secretary of State can be accountable. For example, you can assess and put in place workforce plans but unless they are funded, it is done in vain. There are also actions that are often taken at a national level by government, which can impact on workforce supply and which only the Secretary of State can resist. We have seen national policy influence recruitment and retention: for example, as we moved away from the nursing bursary, as we have seen changes in immigration policy and in the challenges faced by the medical profession around its pensions. All those impact on recruitment and retention.

The Health and Care Bill must have embedded in it accountability for workforce planning and supply sitting with the Secretary of State. This will not only ensure good supply but will prevent staff shortages, improve patient safety and the quality of care. If this is not resolved, we will see those deteriorate.

Finally, on sustainability, we have heard how planning for the workforce takes time. We have heard how long it takes to take train a doctor or a consultant or even a clinical nurse specialty. These periods of training reach over the span of a Government. We need a system that does not just respond to the needs of a Government but beyond them, to ensure that our horizons are not limited by politics but by the needs of a population. Our workforce provides not just quality care to an individual but to a community. We have heard how, if we fail to provide the right workforce, we will fail the other aspirations in the Bill.

Photo of Lord Warner Lord Warner Crossbench

My Lords, I have added my name to Amendment 146 in the name of the noble Baroness, Lady Merron, but I support all the amendments in this group. Taken together and perhaps integrated a bit better, they strengthen the focus in the Bill on workforce issues and workforce planning. I also congratulate the noble Lord, Lord Stevens, on his contribution to open government.

For too long, we have been preoccupied with the funding of our health and care system and have tended to assume—I confess that as a Minister I certainly did this to some extent—that if Governments made enough money available, we would be able to acquire the staff we needed, always forgetting, I think, that health and care is a highly labour-intensive industry, possibly the most highly labour-intensive industry in our country.

We were often very good at masking the shortcomings in our planning system by historically relying on recruitment from abroad. There were doctors from Africa, India and Europe, nurses from the Philippines and elsewhere, and we had a lot of staff coming in from the EU to work in our social care sector. Brexit and our national preoccupation with limiting immigration has changed all that, and that is before we calculate the effect of Covid on health and care staff recruitment. To give your Lordships just one example, pre-Brexit, 40% of the social care staff in London came from the EU. You simply cannot make that ground up very quickly.

Today’s reality for recruiting health and care staff is that we are operating in a highly competitive national and international labour market. That situation will not change any time soon. The probabilities are that we will have to pay more for staff and give more thought to our working practices and conditions. We will have to do a much better job of planning ahead and take much more seriously the training, support and recruitment and retention of this increasingly scarce resource—people.

I suggest that Ministers—I include all of us who have been Ministers—must stop political bragging about how many new doctors and nurses a Government will produce, often without the foggiest idea of how long it will take to do so. Ministers might want to give more consideration as to whether they have the right skills in the sector in the first place, before commissioning the training of highly paid, highly skilled professionals. We have not done a very good job of looking at the extent to which many of the jobs done by doctors could be done by other professionals. Our attempt to train nurses in prescribing has been only half-hearted in using the skills that we have paid for them to develop.

The number of amendments in the Bill that focus on workforce supply and its use is considerable. It is clear from listening to this debate and looking at all these amendments that, across the Committee, there is a strong desire for the Bill to include many more provisions about measuring and assessing the adequacy of the health and care workforce and planning ahead to meet future needs. The amendments in this group make clear that this work needs to be done at both local and national level, and changes in the Bill will need to reflect that consideration. I suggest that we need to get together, across the Committee, to collect and secure the right mix of amendments on Report. The Government would do well to begin discussions with all parts of the Committee on amendments that would meet the concerns expressed today.

While I support the amendments in this group as making a big improvement on the current situation, I do not think they go far enough to deal with DHSC short-termism. The noble Lord, Lord Patel, mentioned the House of Lords Select Committee that reported in 2017. Much more should be done because, as my noble friend Lord Stevens eloquently described, we may not be able to trust any Government to keep their mind consistently on this issue. History is not terribly reassuring on that. I am not making a party-political point; across the parties, there is a danger that we lose sight of this issue when it becomes inconvenient. Even a well-intentioned Health Secretary can be subdued by his colleagues in the Cabinet—I mention no particular names or offices.

That is why I have tabled Amendment 285, which talks about establishing an office of health and care sustainability which would bring together the issues of money and workforce planning. It basically implements a recommendation from the 2017 Select Committee report and is based on the experience of the Office for Budget Responsibility. The noble Lords, Lord Patel and Lord Kakkar, have tabled a similar but slightly less detailed amendment with Amendment 286. Between now and when we reach those amendments, we need to consider whether we are confident that amending the Bill to rely on the Secretary of State doing the right thing, without some independent outside influence, is the right way forward. We want to give the Secretary of State the job, but we also want to ensure that he does it. I mention, if I dare, that the amendment proposed by that 2017 report was put to Jeremy Hunt, who did not act on it—though I am pleased to see that the sinner has repented and decided that there was perhaps some merit in having a national body to look at this kind of issue.

Photo of Baroness Harding of Winscombe Baroness Harding of Winscombe Conservative 7:30 pm, 24th January 2022

My Lords, I add my voice in support of Amendment 170, so ably and brilliantly introduced by the noble Baroness, Lady Brinton, my noble friend Lady Cumberlege and the noble Lord, Lord Stevens.

At Second Reading, I spoke of my personal experience along the timeline set out by the noble Lord, Lord Stevens, as the person charged with developing the 2019 people plan with said absence of numbers. I do not wish to go into more detail on the history; I would rather spend the brief time I have available talking a bit more about why I think this amendment is needed and attempting to pre-empt some of the potential objections which I suspect will come from my noble friend the Minister.

A number of people have alluded to it, but we should be under no illusions that this is the most important debate we will have on health and social care. All our fantastic, lofty ambitions for our health and care system are for naught if we do not have the people to deliver them—and we should be under no illusions that we do not have them today.

I add my voice to those of the noble Baroness, Lady Hollins, and my noble friend Lady Verma: there is undoubtedly an important point about ensuring that healthcare assistants, nurses and managers in social care are paid appropriately. We also need to face the fact that we do not have enough people working in health and care in every single role in the system.

This is not a UK-only problem. As the noble Baroness, Lady Brinton, and the noble Lord, Lord Patel, said, this is a global issue. We cannot rely on people from outside the UK alone to solve our problem; we have to solve some of this ourselves. We undoubtedly need more people, but I would argue that we also need to work differently; we need both more and different. We need to address the way we work in health and social care, which is at the heart of this Bill. We need to embrace new professions and do the forward planning to make that possible, whether that is recognising sonographers as a registered profession; pushing forward on physician associates, where we are some 10 years behind other countries in the world; or developing an approach to credentialling which enables our clinicians to have more flexible careers, as science and technology change through the course of their lives. All of these ways to work differently from the way we operate today are as important as having more people. Neither more nor different is possible unless we start by being honest about the size of the problem, which is why Amendment 170 is so important.

I believe there are two substantial disincentives for this amendment being accepted. A number of your Lordships have alluded to the first one: anyone running a large people-based organisation is always tempted to focus on the urgent today and not invest in training and development for the future. It is just too tempting for the NHS, as well as the Secretary of State and undoubtedly the Treasury, to want to retain the flexibility to focus on the short term and raid the training budget for the future. Any one of us who has run any organisation knows that that is a human temptation. This does not make them bad people and it is not party political; it is just the reality of running a large organisation. That is why legislating to force transparency is so important.

The second major disincentive relates to a view that I suspect has been held in the Treasury for the best part of 20 years and which is counter to most economics. It is a belief that the way to control workforce costs in the NHS is to constrain the supply. I am not a brilliant economist, but most economics is the other way round: the way to reduce the cost is to increase supply. I have no doubt that it is quite a strongly held view in Her Majesty’s Treasury that the way we control workforce costs in the NHS is by constraining the supply. The reality is that that market mechanism is completely failing.

You have to look only at the costs the NHS is paying for locum, agency and bank staff. A recent Getting It Right First Time report, published last autumn, stated that 27% of workforce costs in emergency departments are for locum, bank or agency staff, which tells you that they are not properly staffed. If you are a young junior doctor in your third year in your career and you work as a locum for one week, you will earn £5,800, but if you work for the NHS for one week, you will earn £3,300. We should not be surprised that junior doctors with large student debts want to work as locums, yet we also know that that materially reduces their fulfilment and the quality of the care they deliver. The economic incentives are not working, despite the deeply held view that if we constrain the supply the NHS will somehow magically transform itself.

That is why we need to put this in the Bill. We do need more people, but we also need to drive incentives for transformation, and we will do that only if we face into the challenge. Those working in higher education can plan only if we give them a signal, and transformation teams can challenge the way we work only if we are honest about the need for that transformation.

One final reason I really urge my noble friend the Minister to accept this amendment is that our wonderful people, who have worked so hard in health and care over the last two years, need hope—and we can send them the strongest signal of hope that we really hear them, that we really understand the people challenges that they face, by putting this in the Bill.

Photo of Lord Kakkar Lord Kakkar Crossbench

My Lords, I support Amendment 173 in the name of the noble Baroness, Lady Merron, to which I have added my name, and I broadly support the amendments in this group.

Many noble Lords have identified the question of workforce as the most important single issue that the Bill has to address. Without effective workforce planning, the NHS, as we have heard—and, indeed, the care system—is in peril. Previously, our country and the National Health Service have depended on overseas doctors and nurses to come and fill large numbers. That has been the principal basis of workforce planning for many years—indeed, decades. But that is no longer a viable option. The World Health Organization has estimated that, globally, there will be a shortage of some 18 million healthcare professionals by 2030. That will be a particularly difficult challenge across the globe, and it means that we can no longer depend on importing healthcare professionals to meet our ever-increasing needs. This is well recognised by all who are responsible for the delivery of healthcare and, indeed, by Her Majesty’s Government.

The question is: how can we dependably plan for the future? Unfortunately, it has to be accepted—indeed, it has been accepted in this debate—that planning to date has failed miserably. That is not a malicious failure, but it is a reality, and one that we can no longer tolerate. That is why amendments in this group that deal with the requirement for independent planning and reporting on a regular basis to provide the basis for determination and projecting future health and care workforce needs, are appropriate—indeed, essential.

My noble friend Lord Warner raised a separate issue about a group of amendments that will come later in the Committee’s consideration, which propose the establishment of an independent office for health and care sustainability. This is a recommendation of your Lordships’ ad hoc Committee on the Long-term Sustainability of the NHS and adult social care, chaired by my noble friend Lord Patel. It is this emphasis on ensuring that there is independent, long-term planning and projection that can provide the fundamental and accurate foundations for workforce planning. We need a broader assessment of what the demand for healthcare will be, and that demand is complex and driven by not only demographic change but changes in the way that we practise, changes in expectations, adoption of technology and changes in working practices. That all needs to be brought together to provide the foundations for planning. Without this emphasis and this obligation secured in the Bill, the NHS and adult social care in our country will not be sustainable.

I very much urge the Minister, in considering this group of amendments, to help your Lordships understand why it would be wrong to secure this emphasis in the Bill. If Her Majesty’s Government are unable to secure this emphasis in the Bill, how can they reassure noble Lords that the failures in planning that have dogged NHS performance with regard to workforce over so many years will not be repeated in the future?

Photo of Baroness Finlay of Llandaff Baroness Finlay of Llandaff Deputy Chairman of Committees, Deputy Speaker (Lords)

My Lords, to state the obvious, without a workforce plan we cannot have a workforce. Amendment 170 certainly seems to get to the heart of the issue, which was so well introduced by the noble Baroness, Lady Cumberlege, and my noble friend Lord Stevens.

Others have spoken about the medical and nursing workforce, and therefore I will not repeat those comments. I want to put a plea in for the allied health professionals, because many of them work outside the NHS, so, while we talk about NHS planning, we will undersupply chronically if we do not recognise where else they work. Some 25% of physiotherapists work with other providers such as the military, prisons, hospices and occupational health services. Some 50% of podiatrists work outside the NHS, and speech and language therapists often work with people in education as well as in the criminal justice system, social enterprises, and in the voluntary and third sectors. That is why I tabled Amendment 172.

In Amendment 214, I have tried to address the problem that Clause 79 abolishes local education and training boards. As the noble Baroness, Lady Harding, said, without access to education, time for CPD, funding of courses and backfilling, we will not get the rapid movement of our staff into different areas as the provision changes. Such local assessment could then feed into national planning processes, as outlined in Amendment 170.

I will give a few bits of data to support Amendment 174 on social care, to which I added my name. Skills for Care found that 24% of the adult social care workforce are employed on zero-hours contracts. That means that they cannot get mortgages, et cetera. Care workers represented the highest proportion of workers on zero-hours contracts, at 35%. Those on slightly higher grades are more likely to have full contracts. In the community, a Community Integrated Care study found a gap of £7,000 between equivalent roles in social care and the NHS. With that large gap, it is hardly surprising that social care does not retain its staff. There is no joined-up recruitment yet, and there is no local or national training planning that covers health and social care.

This group of amendments is absolutely essential, and it would be a dereliction of our duty to ignore the messages from this debate.

House resumed. Committee to begin again not before 8.30 pm.