Some of our witnesses will be giving evidence today by video link, while others will appear in person. It is helpful, particularly when witnesses are giving evidence by video link, if Members could direct their questions to specific witnesses. Before calling the first panel of witnesses, I remind all Members that questions should be limited to matters within the scope of the Bill and that we must stick to the timings in the programme motion that the Committee has agreed. We have until 10.30 for our first panel. Do Members wish to declare any relevant interests in connection with the Bill?
I have no relevant interest to declare, but we are unable to see a screen. Would it be possible to erect a screen so that we can see those giving evidence?
Yes, we can do that. As there are no witnesses giving evidence in person, it would be okay for Members to sit at the witness table, if that would be better.
I want to declare an interest as a medical practitioner, although not commonly practising, and as a member of the British Medical Association.
Thank you. I am very keen that we continue this session as quickly as possible. We will now go to our witnesses. Good morning and on behalf of the Committee, thank you very much for agreeing to give evidence. Please introduce yourselves for the record.
Good morning to you both. Having taken big Bills through Parliament before, I am aware that a lot of scrutiny goes into the detail on the statute book, for obvious reasons, but sometimes we also need to reflect on the implementation and how we can make the legislation turn into a reality. Q Based on the proposals in the Bill, what role do you think you can play to bring about that reality through the development of the workforce to meet the demands on the healthcare system that the Bill is trying to improve the prospects of meeting?
Dr Navina Evans:
Thank you very much for the invitation to give evidence today. I am really pleased to note the prominence the Bill gives to the workforce, and the important focus on systems working together, and working together with social care. I think that implementation will work well because we can build on what we are already doing. There is a great deal of collaboration between all parts of the system, and I can give you lots of examples if you wish of how we have developed the workforce over the past few years, particularly through the pandemic. We can build on what we have done together with other parts of the system. HEE plays a unique role because we have relationships with educators, providers of healthcare, the regulators, the professional bodies and NHS employers and other partners, as well with NHS England and the Department of Health and Social Care. We play a convening role, and we have already used that experience, ability and capacity to develop the workforce so far. We think the Bill will enable us to build on that.
Navina captures really well the work that is already going on, not least, as she has said, through the pandemic. My members, who are the trusts and ICSs around the country, are already trying to find ways of developing joint approaches to developing their workforce, not least with their colleagues in social care, but also by thinking about different ways in which they can recruit and perhaps make employment in the NHS more accessible to people from harder, under-served communities. Some fantastic work has been going on with the Prince’s Trust, for example, around the NHS, and that has increasingly been done through the organisations that are being formalised through this Bill.
I also think that the commitments that the Government are expected to make later today, not least around investment in social care, will help organisations to work together. We have a pressing need in the health service to invest in the longer term in our workforce, but that is even truer for our colleagues in social care. Again, that is a significant step forward today, which we hope will go even further in the spending review, in helping employers to ensure an adequate supply of people in the longer term, not least with the support of Navina’s organisation, and also by being able to innovate together in developing roles that better meet the needs of the communities they serve.
Q Do you see the principles set out in this Bill, along with the details in each of the relevant clauses, around integration and collaboration as a natural progression from a lot of the work that has already been undertaken by yourselves and others working in the healthcare system?
I agree with that. I think there are some risks. At the heart of the Bill, it is formalising organisations that can lead, innovate and perhaps do things differently from each other in local areas. We have a very centralised healthcare system in this country, and one of the risks is that the vision in Bill of integration and devolution to local areas is not realised, because the centralising impetus is very strong. However, the Bill absolutely captures what has now been many years of growing collaboration and integration between health organisations but also, importantly, with our colleagues and friends in local authorities and social care.
It is really interesting to hear—I have seen it, as I am sure you all have—how partnerships have been built through covid. There has been a huge amount of joint working and integration. Have you been able to pick out any specific areas of learning over the past year and a half that we would hope to see as we go forward and which would be really useful as we build this integrated networkQ ?
Dr Navina Evans:
I can give you three areas of learning that we in HEE were really pleased to see. One is around flexibility and better collaboration, which meant that our students and learners had a different kind of learning experience and also were able to contribute in a very real way to the care in service. This has led us to build on the reform agenda for education and training, and we are working with partners in education, the professional bodies and the regulators to see how we can use what we have learned to enhance that.
That is the first thing; the second thing is that we have seen quite a lot of barriers between organisations and systems being broken down. Again, that is something that we in HEE feel we should make the most of, together with partners, for future ways of working. The third area is the use of technology, digital and new ways of working. We have really moved quite significantly in how we work, including in how we learn, teach and train. Again, those are areas that we are very excited to build on. In many of them we had started before, but we accelerated during the pandemic, and we will not be going back. We will only be moving forward.
I think that Navina captures really well that catalysing effect that the pandemic has had. I think that in many parts of the country there has been a much greater sense of there being one team within localities and communities. There have been some fantastic examples of health and social care teams coming together to respond, given the particular impact of the pandemic on social care settings and on the most vulnerable members of our communities. There is more to do, but the recognition that actually there is one workforce and one team, cutting across the NHS and other health organisations in other parts of the public service, is absolutely growing.
I think that the Bill, by formalising arrangements and stretching what is expected of systems, provides real opportunities for those systems increasingly to inform the kind of national work and planning that Navina and her colleagues lead, as well as the kind of informed work that the Secretary of State and the Minister want to take forward for health and social care.
Q I am interested to hear your views on the adequacy of the requirements for workforce projections within the legislation as it stands, in relation to both the NHS workforce and social care, potentially, and how you think the devolved Administrations should be brought in. Dr Navina first, please.
Dr Navina Evans:
HEE has recently been given a ministerial commission to lead on developing a strategic framework for future workforces planning. We think that this is really timely in relation to the Bill. What we feel really matters in workforce planning is driving actions and solutions. We need to be able to identify future needs and shortages, and then ensure that the systems develop plans, but these plans need to be able to access all levers at all levels. It is quite a complicated business, but we feel that it is timely for us to pay particular attention to it.
There are a number of areas to consider. We need to look at service redesign; workforce redesign and transformation; employer roles, in terms of retention and recruitment; other supply interventions, such as international recruitment; and then—this is particularly relevant for HEE—future supply through education and training. We then want to pull the system together, through our convening role in HEE, and to have two principal ways of thinking about this: the future needs more and different, in terms of workforces and people; and we want to focus on skills, not necessarily just roles. The really critical point about this commission is that it asks us to ensure that we include the regulated social care workforce in our planning, which is a real step forward. We are looking to ensure that planning should track long-term trends in demand, that we should not be too tied to short-term fiscal cycles, and that we are prioritising supply for the whole health and care workforce.
It is very welcome that the Department has commissioned HEE to do the work that Navina has described, but the NHS Confederation is clear, alongside a whole range of other organisations that work on behalf of the health service in particular, that clause 33 is insufficient for the task that the NHS faces in workforce planning. What it sets out, as Committee members will know, is a requirement for the Secretary of State to describe the process of workforce planning every five years. We have proposed to Parliament that that needs to move from setting out the process to actually setting out the requirements that health and social care have, and to do that much more regularly—we propose every two years.
For us, what is in the Bill is positive, because it is good to have the process described for the first time, but actually, as Dr Evans has just touched on, we need to spell out what the health and social care systems need in the longer term, but also in the immediate term. In some ways, that would mirror the work of the Office for Budget Responsibility in terms of advising the Government and Parliament about likely health and social care spending. We then need a corollary that sets out what is needed to respond to that in terms of people. Health and social care is fundamentally made up of the 3 million people who work in it. We sometimes fixate on the buildings and the technology, but it is fundamentally, in its essence, a people business. We think that that is a pressing issue, not least because of the pressures we face. That is not to say that the Government have not and do not invest in workforce numbers—significant decisions have been made in recent weeks around expanding medical school places, for example. But what we do not have is one coherent, single plan that is presented to the country and particularly to Parliament, which sets out what the NHS and our friends in social care will need to meet the demands that are being placed on us by the population, their health needs and quality of life, and also of course any priorities that the Government might set for social care and health services.
I appreciate that people working together and perhaps substantiating some of those informal arrangements might, in theory, do some of what you hope. However, the employers remain the institutions that make up the integrated care boards—that is the effect of the Bill. You have started to talk about the process. Could you perhaps talk a bit more about how that is enforced, what that means in practical terms for employers and how employers might behave? I am partly thinking of one of the trusts in my area, which, a number of years ago, set up a wholly owned subsidiary company, with the benefit for them of different terms and conditions for staff as a way of saving money. That was obviously detrimental to the healthcare system generally because you are competing for the same sorts of staff. We made the trust stop doing that because we wanted the staff to be treated the same. My point is: the employers, the terms and conditions, the benefits and the way that they will attract staff remain the same. The Bill does not make the ICB the employer or the way to deliver those terms and conditions or ways of recruitment. I think it is a theory. Can you convince us otherwise and show how in practical terms the Bill solves some of those problemsQ ?
It is absolutely the case that the individual organisations in the NHS, social care, charitable organisations and local authorities that make up the partnership as well as the board will remain separate legal entities. We do not see that it is desirable for the NHS to move from having 250 separate employers to having 42 employers. What we have in the NHS is a set of national terms and conditions. My organisation has a particular responsibility on behalf of the Secretary of State to negotiate those with our trade union colleagues. We see that they work well for the NHS and I detect no movement among my membership to move large scale away from those national terms and conditions, which cover the vast majority of staff who work in the statutory NHS.
What we see with ICSs is that organisations are increasingly coming together to address shared challenges. We observe that those challenges are not about pay and conditions but about supply. They are about working together to think about how to promote a specific area for people to come and work in, whether that is Nottinghamshire or West Yorkshire and Harrogate, where there has been some fantastic work in promoting careers in the sector as a whole. We see people coming together to work with directly elected Mayors around the skills agenda. There has been some really fantastic work, for example, in the west midlands, with health and social care organisations coming together with local authorities. We see similar work and engagement with the Mayor of London on the skills agenda that he is taking forward. Again, that is being done by organisations working together. That helps partners—local authorities are engaging with health and social care as a team rather than dozens of separate organisations. It also helps us promote careers that span the whole range of settings that we operate in and speaks to the particular priorities of our colleagues in social care. We see some really fantastic examples of that in various parts of the country.
Finally, we see a real opportunity to take forward the work that I have just talked to Dr Davies about. Systems, as they look at their services and their knowledge of the things that they are providing in their communities to your constituents, can inform the national plans that Navina described in her answer to Dr Davies. We can have a much greater connection between local priorities and some of the decisions that are made nationally about how we invest longer term in education. Of course, the NHS workforce is about 50% degree educated or degree equivalent. So there are significant investments that the Department of Health and Social Care, the Office for Students and the education sector make in our workforce. Being able to root that in what it is that local services need and how they are developed seems to us like a fantastic opportunity, and would help us to avoid the problems that we have got into in the last couple of decades with pressure points in various parts of our workforce.
Dr Navina Evans:
I will build on what Danny has just described. You have given some really good examples of how local employers are coming together in systems to address workforce issues. I would add a bit more about how we do it and how we can do it even better going forward. Health Education England has a role in developing careers and attracting young people—all people—into the health and care workforce. We play a really big part in that. First, we have found that doing that locally, at a very local level with the communities and organisations that really understand their local populations, has been a really good thing to do. Some of the examples that Danny gave have built on that and we will move forward on that.
Secondly, we have structures in which people boards, at integrated care system level and definitely at regional level, now bring collections of the different organisations together. We have systems that are starting to think about themselves as anchor systems, which means that they can influence employment, the economy and the success of local communities.
Finally, the population health issue has been something that we have really woken up to, and we are cognisant of the fact that we have to focus on and rebalance the health and wellbeing of the population. Through the pandemic, we have learned a lot more about where we need to target our efforts to reduce inequalities. That can only be done really well through collaboration at a local level. Organisations such as mine need to work closely with our partners in NHSE, with the Department and with other national organisations to make sure that we support those local efforts to be sensitive to the needs of their particular population. It is bringing the national priorities, principles and policy into life at a very local level by making sure that we have the systems and structures in place to deliver what is needed locally. We had already started working on that—the work is well under way—and the Bill will enhance our ability to get on with doing that.
I want to return to the issue of workforce planning, which obviously is integral to both of your organisations. You have discussed the strategic framework you have been working on, and hopefully that will evolve into a workforce strategy, which is addressed in clause 33 of the Bill. I have tabled an amendment to clause 33 which is to make the workforce report annual rather than once every five years. I think that the pandemic has demonstrated the futile nature of trying to produce a report once every five years, when we know that the nature of the workforce could change radically during that period. Would your organisations agree that it would be better for that report to be produced on an annual basis? Clause 33 states that NHS England and Health Education EnglandQ
“must assist in the preparation…in this section,” but only
“if requested to do so by the Secretary of State.”
You have talked about locally led decision making and planning. Do you both agree that we need better co-creation? My amendment covers the fact that a plan should be developed and agreed by stakeholders in particular. Would your organisations welcome this amendment, which would result in an annual workforce strategy and require it to be developed by all other healthcare organisations working in this sphere?
Dr Navina Evans:
From HEE’s perspective, we will deliver on the duties that Parliament decides that we ought to deliver. We feel that we have the capacity and the capability. We can organise ourselves to deliver whatever is required of us by the Bill. The work that we do is lithe—it is iterative. We do iterative planning, in a meaningful way, at the national and system level, so we will be able to respond and fit in with whatever is required of us by the Bill and Parliament.
Thank you for the question. Absolutely, there is an opportunity for the Bill to define a wider range of stakeholders. The systems at the centre of the Bill—integrated care boards and integrated care partnerships—are central to that, and their perspectives, as we have just talked about with Ms Smyth, in terms of the needs of their population and the services they need to put in place to respond to them, need to be at the centre of the process that Navina and others would lead on behalf of the Secretary of State. That is the first thing. Secondly, there is an opportunity through those systems to broaden our conversation to include social care as well as health. That is really important to us on this day of all days, in terms of the announcements later.
In terms of the regular appraisal, we absolutely believe that five years is absolutely insufficient for the task. We also believe that it cannot just be about process. It has to be about setting out clear requirements and clear specificity about those requirements over different time periods. There is something about the short-term need, and there is also something about five, 10 and 20 years. It needs to be regular. We have proposed two years because it is a huge amount of work and that feels to us to be a minimum in terms of how regular the perspective could be, but it may well lend itself to an annual update, as you have described.
We also see that organisations such as Health Education England and Skills for Care, which operates in the social care sector, absolutely have the capacity and capability to lead this work. Their way of working, similar to the Department’s way of working throughout the preparation of this Bill, is about engaging, convening and trying to bring stakeholders together to get a broad range of perspectives. That is our experience of the long-term process that Navina and her colleagues are leading on behalf of the Department at the moment. The Bill confirming that would confirm ways of working that we are starting to see develop with stakeholders in a really healthy and constructive way.
Good morning. This Bill is mainly about services in England, apart from the part about the health services safety investigations body and clause 112 on Welsh health bodies requesting help. However, there is significant traffic from Wales to England, and a certain amount in the other direction, to access health and care services. This might impact on services in the north-west of England and along the Welsh border. This is a very broad and quick question: in what ways do you see yourselves and other health bodies in England taking account of the priorities and needs of the Welsh Government and of the Welsh population to access health services in England?Q
There are important links with Wales, and of course with Scotland as well, in many parts of the country. There are a couple of things to say. The first is that there are undoubtedly things that the English system can learn, and is learning, from our colleagues in Wales, Scotland and Northern Ireland who are taking similar approaches in terms of how they respond to the challenges we face in social care and health. In my own organisation, we represent organisations in Wales and Northern Ireland, and there is a really rich learning that we can do there.
Secondly, in practical terms, there are good lines of communication and liaison between healthcare organisations that operate along the borders that you have described. It will carry on being really important that those lines of communication, that liaison, the financial arrangements and the sharing of care between different teams on various sides of the borders continue, and we see nothing in the Bill that prevents that. If anything, we see opportunities through better co-ordination in England at a system level to be able to help patients who travel across from Wales into England, or patients who travel from Scotland into England. If anything, I think we can improve the planning and liaison through what is in this interesting Bill.
Dr Navina Evans:
We already have very strong four-country relationships, particularly in the education and training space, where we make sure that we share standards, that we do planning around the curriculum and the reform of education, that we ensure quality and that we go for improvements in the way in which we support and train our future healthcare workers. In the regulation space, we work very closely with the General Medical Council, the Nursing and Midwifery Council and other bodies, to make sure that that happens. They obviously have four-country oversight, so we already work very closely with them. Also, all our professional bodies, such as the royal colleges, have to represent members from across the whole UK. In that space, there is a lot of good work that we can continue to build on, learn from and share as a result of this Bill.
Q I am very glad to hear what you have said. Professional staff are notoriously footloose, as far as Wales is concerned, so there is a certain issue about workforce planning. In my own area, I used to teach in social work education. We have a nursing school at Bangor University, which is a very valuable provision, but I am not sure how many are retained in the health service in Wales—or the other way around, of course.
There is one other point I would make, and this is more philosophical than practical. The Welsh Government’s approach to health is based on a wellbeing model. It is much more proactive than other models. I hope that, philosophically, that sort of approach is useful and interesting for you, and that you will be taking full notice of it.
The second point, in particular, is really well made. That is absolutely the focus that we see integrated care systems taking. The engagement with population health that Navina described is about trying to gear a system much more to long-term investment in the quality of people’s lives.
We have become, in recent years—even before the pandemic—much more geared towards crisis response. That is not in the best interests of the long-term health of the population. It does not help us to address the inequities that we see in our population, and that we saw very starkly during the pandemic.
Navina may be aware of the issues around workforce mobility between the four countries. The co-ordination that Navina leads, and that we have with our professional regulators, is really important. We have a shared workforce, and we have shared approaches to education as well as things such as pay and contracts. That is really important to ensuring that the job market is stable, particularly if we experience supply issues in particular geographies or parts of the workforce.
Dr Navina Evans:
I have nothing to add on the movement of the workforce between the four countries, but I take the point that this is something we need to be mindful of, and I will make sure that the issue is a priority in our conversations with our counterparts in the four countries.
On wellbeing services, that is absolutely the way in which the reform of education and the curriculum is moving. Health Education England is working with partners to develop that. Our integrated care systems, and our colleagues running services who are closest to the point of care, and who know their populations best, have been saying for some time that we need to focus on wellbeing, prevention, intervening earlier and keeping people well. That is a priority for our partners in NHS England and NHS Improvement as well. We already have programmes of work to take this forward.
Good morning. Thank you for coming. I am sure that you will be aware that everyone in the country, and the Q whole Committee, is very grateful for the work done by frontline health and social care staff, not only over the past 18 months, but over many years. The consequences of that work have been starkly drawn to everyone’s attention by the Health Committee report on staff burnout. What in the Bill will address the issues raised in the report?
Dr Navina Evans:
I will give you three points that are really important. One is the absolute priority, focus and prominence given to looking after our workforce. Again, we will build on work that we have already been doing in the last few years. For example, in the interim pupil plan, there is a very strong focus on wellbeing, culture, leadership and retention. We have been working, together with Danny’s organisation and others, on thinking with staff about retention. One thing that is really important is looking after people. There are lots of good examples of work being done all around the country to improve wellbeing and therefore retention, and to minimise or prevent burnout. This is quite high on the agenda for our partners in NHS England and NHS Improvement. It is very high on the agenda for us in HEE, because we look after our students, trainees and learners, who are also part of the workforce, and they tell us what helps to keep them well and prevent burnout. We need to start doing that work, which is part of our business, very early on.
I am pleased to say that our partners in the universities, royal colleges and other professional bodies are really mindful of this. They all have work streams around wellbeing and preventing burnout. In the Bill, we can highlight the importance of this, and build on work that is already being done to look after our staff.
Noted, Mrs Murray.
I agree with everything that Navina has said, and it is a huge focus for the health service. In terms of supporting the health and wellbeing of staff, I think the Bill can go further under the terms of clause 33—it represents the conversation that we have had with them a couple of times. Absolutely we should support people and absolutely we should care for them, but if there are gaps in their rotas and in their teams that only increases the pressure on people who are already working flat-out. The pandemic has shown us starkly where those gaps and needs are, but we were experiencing them before the pandemic. There are parts of our workforce—mental health, learning disability nursing and some of our smaller allied health professions, such as therapeutic radiography—that absolutely need urgent long-term investment. We need that investment in staff as well as in the pressing need that we saw covered in social care settings and in hospitals during the pandemic. The requirement for a regular assessment of what the health and social care system requires to meet the needs of the population would help us to support that.
Q You were very clear in your view of what was needed to make clause 33 more effective. In your opinion, would the clause also require some funding requirements to meet the demand?
I do not know to what extent Parliament is able to, or is willing to, pre-commit Governments to funding decisions such as you have described. Absolutely, that would bring clarity for us all in terms of what was needed, and it may well offer clarity in terms of the prioritisations that we have to make on investment in the workforce. We have seen a massive expansion in our medical workforce, particularly in hospitals, in the past 20 years, but we have not seen a similar expansion in the nursing workforce. That is not something that was clearly set out for us and for a Government to help make decisions about. I think a clearer, more effective clause 33 would help a Government to do that, and in turn help a Parliament to support a Government in that.
Q Thank you. I have a quick question for Dr Evans, and then one more question for you both. You have mentioned the commission that you have been asked to form to draw up that strategy. When is that expected to be published?
Q May I ask you both whether you have given any thought to, or been able to quantify, the amount of staff and management time that will be taken on implementing the Bill?
Dr Navina Evans:
From our perspective in Health Education England, our input is quite confined to the workforce planning. We are able to manage within our existing resources and to redefine and redeploy them. We are also able to work collaboratively with partners who are very willing to help us in this work.
I cannot give you an exact figure, Mr Madders, but I can reassure the Committee that the way in which the proposed change will be implemented is much more about minimising the organisational disruption change that we have experienced with previous reforms, either the one 10 years ago or the one a decade before that. We are seeing a clear commitment to move staff who are currently employed in clinical commissioning groups—the Bill will disband those groups—to the new ICS organisations. That is a very positive way of managing the change rather than that experienced previously, which was hugely time-consuming in terms of management time and hugely unsettling for vital staff in terms of planning services. We are avoiding the problems that we faced in the past. Amanda and her colleagues at NHS England are to be commended for the proportionate and sensible manner in which they are looking to implement the changes, especially in terms of how they impact on people and organisations.
I have a very quick question for Danny Mortimer. You have the unenviable task of negotiating with the staff and their representative unions on all sorts of issues—pay, terms and conditions, safety. When you have such negotiations, how high up on the list does a commissioning restructure come in terms of the things that our front-line staff are really after?Q
We have a really constructive set of relationships in the NHS with our trade unions, on both terms and conditions and the social partnership forum, which the Minister’s colleague Helen Whately chairs and which brings trade unions and employers together.
There is an interest in how the health service organises itself, and there is an interest in how the health service and our friends in social care can better work together to relieve the pressure that our colleagues were experiencing even before the pandemic. Of course, there are other things that people are interested in as well. There are outstanding questions about long-term pay strategy, and there are other issues around working environments and support that Navina touched on. Those are really important as well.
There is a recognition, when I speak to trade union leaders and representatives, of the opportunities available through system working to improve service delivery, and therefore to help their committed members do their jobs better and relieve the pressure that they have been under for far too long.
Q Thank you very much, Mrs Murray. Dr Evans, we have talked quite a lot about workforce and highlighted the fact that the workforce move around the UK, and therefore work in the four different nations. Registration of nurses and doctors is UK-wide, although only Scotland has registration for care staff. Do you not think that that needs to be recognised to some extent in clause 33, so that we do not end up having Peter robbing Paul? This year, we have seen a shortage of foundation places. Although all four nations have increased medical student places, a young doctor cannot practise unless they get their two years at foundation level. Do we not need to be consulting specifically with the other health Ministers and looking at the workforce in general? I do not mean transferring control of that workforce, but recognising, for the next five, 10 or 20 years, the needs and the strategies of the different nations so that we do not end up stealing from each other.
Dr Navina Evans:
Thank you for the question. It is for Parliament to decide what goes into the Bill. We will, of course, work accordingly with the duties. We already work with the four nations around the foundation year programmes, we share a lot of intelligence and recruitment work and we are continuously looking for ways to strengthen that. It is an important priority for us to share learning and recruitment between countries.
Q Sorry to interrupt, Dr Evans, but this year the foundation places are managed on a UK basis, and this year, at the beginning of the summer, there were several hundred graduates who did not have a foundation place—I hope they have all got one now. That can mean people literally being sent to a different part of the UK, away from their family and their support mechanisms, and we all know how tough these years are. This is being managed at a UK level, and yet the three devolved nations are also trying to tackle workforce issues. If they are not included in this, or at least consulted, do you not see that as a weakness?
Dr Navina Evans:
I see that we are addressing exactly those problems around where people go to do their jobs and where the placements are. Having to travel to get the right training jobs is something that we have been grappling with for a very long time in Health Education England, and I remember that we were grappling with it when I was a trainee. That is something that we focus on anyway, and if it were to be strengthened in the Bill we would, of course, look at the duties that were expected of HEE in terms of working across the four nations to solve this issue. We would be building on what we are already doing to address that.
Q Thank you. Danny Mortimer, we have talked about the change that is coming, and a lot of it is to enable the innovation that has come through the pandemic. I was back in the NHS in Scotland in the first wave, and I saw that creativity. How do you think it can be done without consuming a lot of the bandwidth of frontline staff? You talked to the shadow Minister about management, but it often takes up frontline staff. Would you see a gradual change? Are you concerned that the footprints of some of the ICSs that have already evolved are apparently going to change? Is that not going to add new upheaval in certain geographical areas?
Thank you, Dr Whitford; there are a couple of things there. On the geographical changes, what ICS leaders wanted was clarity. They have now been given that by the Department and NHS England, and they will move forward and can adapt accordingly.
On the impact on the frontline, throughout the pandemic, and increasingly before it, we saw a much greater sense of teamwork across some of the boundaries that we can create between parts of the health service, and between the health service and other public services. There is an opportunity to accelerate that in lots of our settings. That will be a positive. It will help people care better for their patients. Most importantly, it will help patients and their families to have a much more seamless experience.
This is not a magic thing—you know yourself how complicated the hand-offs and transitions between different teams can sometimes be—but this Bill formalises the recognition that we have had over recent years in England that to start to properly and truly focus on what individuals need, we have to have better co-ordination between our teams. It is not about the institution first; it is about the team first, and obviously most importantly the patient first. The absolute opportunity for us is to do those things better for the patients in between our services.
Q Yes, I totally recognise that. In Scotland, we reintegrated primary and secondary health back in 2004, and in comparison with the last seven years of trying to integrate health and social care, that was a walk in the park. It is much more challenging, but equally it is where we are all trying to get to. If I can ask you, on a different subject—
This is the last question.
On the health services safety investigations body, I was on the pre-legislative Committee, where there was an aim of protecting the safe space disclosures quite thoroughly to ensure staff had the confidence to discuss very sensitive issues. In the version that is in this Bill, much more is covered by safe space protection, but then there are exemptions such as the coroner. Although staff can be summoned and made to give evidence, if they feel that that will end up being shared through a lot of disclosure exemptions, do you think they will really believe that that space is protected, in the way it is in the airline sector?
There is a very difficult balance that health service leaders know they need to strike. The requirements around transparency to the public are much higher for the health services and for people such as you and Dr Evans, as health service practitioners. The coroner’s ability to review what happened is a really important step for families, and we are very respectful of that.
What the Bill does—this is how it describes the investigations branch—is to build on work that the NHS and the Government have been taking forward since Robert Francis’s inquiry into whistleblowing to ensure that we have cultures, practices and processes that enable people to be candid and open without fear of consequence, in terms of what has happened. We realise that that is how we learn and improve. We also realise that have a lot of work to do to help all parts of our workforce—clinical and non-clinical—feel much more comfortable and supported to raise concerns, give feedback and be honest about what happened. As you will know, there is an enormous amount of work going on across the four countries to create those kinds of cultures, but at the same time, we also recognise that we have that responsibility in terms of transparency to the public, and to patients and their families.
Q Thank you, Mrs Murray. I will try to be brief, with just two questions. Morning, Danny; morning, Navina. My first question is this: what do you see as the potential role of legislation in addressing future workforce needs— both the limitations of legislation in doing it and the opportunities?
Dr Navina Evans:
I will start with the opportunities. We in HEE are really pleased to see that workforce is prioritised in the way that it has been. For us, that means that there is an expectation and an understanding of the need to tackle complex issues of future workforce planning, and that is hugely important. We can do it; it is a difficult task, but through collaboration and bringing people together, it is something that we simply must do, so that we can have more and different, and we can be really future-focused and progressive in the way that we deliver health and care. It is all down to our workforce. So that is the huge opportunity, as we see it.
There are risks. For us, one risk is that too much bureaucracy and added layers of hoops will get in the way, and the other risk is that we have to work hard to make sure that we address culture and collaboration to make this truly successful.
The opportunity, we believe—along with colleagues across the health service—is in clause 33, going further and deeper there in terms of the assessment of need, as well as an assessment or a description of process. Clearly, what legislation cannot do is set out the kinds of behaviours that make that a well-informed and inclusive process. To reassure the Committee, though, what I do see is that the way of working we experienced during the development of this Bill, the way of working we are experiencing with Dr Evans in terms of the process she is leading at the moment—the long-term framework—is inclusive. It is trying to bring different voices in. Difficult decisions may well need to be made about prioritisation, and we understand that, but that is much easier to do and much easier to understand if it is based in that kind of process and behaviour. However, clearly, that is one of the risks.
As I have already said, we have had an increasingly centralised healthcare system over these last few years, and that is also one of the risks. If we stifle the local leadership and local innovation, and if we do not seek that local input in terms of how the development of local services needs to inform, in particular, the long-term planning for workforce, then that is a real risk for the legislation.
Q Thank you. One final question from me, if I may, Mrs Murray. I think it was Dr Mortimer who touched on a couple of points in his comments. One was that the way it is envisaged that this will be implemented would minimise any impact or burden, as it were, on the system, and I think that both witnesses touched on the learnings from the pandemic—the opportunity to build on what was done during that. To what extent, or not, would the witnesses consider that this is the right time to be doing this?
Dr Navina Evans:
We in HEE think this is absolutely the right time to be doing this. We are at a moment where we have a lot of learning from what we have been through this last year. We have a real opportunity where many different pieces around innovation and improvement are coming together, and we have learned a lot from our previous experience of delivering the Health and Care Bill. For us, we think that this is absolutely the right moment to be doing this work.
We would agree. NHS Confederation members were clear about the need for this approach before the pandemic, and I think that is even more pressing because of the pandemic. Actually, given the announcements that the Prime Minister is expected to make later today, it reinforces that need to better integrate health and social care, so the timing is very good.