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Tracy Brabin (Batley and Spen) (Lab/Co-op)
I beg to move,
That this House has considered staffing levels in the NHS.
It is an honour to serve under your chairmanship, Mr Hollobone. It is a pleasure to lead this debate and I thank hon. Members for being present. I know that many are eager to contribute, and the fact that they have taken the time to be here, during one of Parliament’s more eventful weeks, emphasises the strength of feeling in the House about staffing levels in the NHS. I also thank the many organisations that have contacted me, offered support and shared their research.
It is clear that the issue of staffing in the NHS is a great and growing concern to many. Indeed, the case of my local NHS trust inspired me to apply for this debate. Most of my constituents rely on the Mid Yorkshire Hospitals NHS Trust for a range of acute hospital-based and community services. The trust serves not just the people of Batley and Spen, but more than half a million people across Wakefield and North Kirklees.
Paula Sherriff (Dewsbury) (Lab)
I thank my hon. Friend and neighbour for securing this important debate. My constituents also use the Mid Yorkshire Hospitals NHS Trust. There are still several hundred nursing vacancies there, and that is having a significant impact on the delivery of patient care. Does she agree that the chaos of the current Brexit situation is not helping to recruit nurses, potentially from the European Union?
Tracy Brabin
I shall go on to discuss that in more detail, but my hon. Friend and neighbour is absolutely right. We have both been in meetings with the trust where that has proved to be of great concern to it.
John Howell (Henley) (Con)
On a similar subject, is the hon. Lady aware that Oxford University Hospitals agreed today to fund the cost of obtaining settled status for EU nationals who work there?
Tracy Brabin
That is something that we have discussed with our trust. The cost should not necessarily fall on the shoulders of the people we want to employ, so that seems like a good thing.
Gloria De Piero (Ashfield) (Lab)
For Sherwood Forest Hospitals trust, which covers King’s Mill Hospital in my constituency, the latest figures show 200 nursing vacancies and, since nursing bursaries were abolished, a 32% decline in those applying to do it. Is it not time to bring nursing bursaries back?
Tracy Brabin
I absolutely agree that training for this most lauded position should not be done at the cost of nurses themselves.
Jim Shannon (Strangford) (DUP)
Does the hon. Lady agree that we must have fewer medical quangos and more medical professionals in their white doctors’ coats seeing patients; less cleaning up of paper trails and more cleaning up in wards and A&Es; and funding that is targeted at frontline staffing and reasonable rates of pay?
Tracy Brabin
Certainly, funding and support should be given to frontline staffing. I will go on to talk about how I see that playing out.
The Mid Yorkshire trust is a major employer of about 8,000 members of staff who operate across three hospital sites: Pinderfields Hospital, Pontefract Hospital and Dewsbury and District Hospital, which is in my constituency. Like many trusts across the country, the trust is feeling the pressure on recruitment. In the most up-to-date figures, which were given to me directly by the trust this week, there is a 10% vacancy rate. That includes 95 full-time-equivalent posts for medical staff, 209 vacancies for full-time registered nurses, and vacancies for all other posts covered by the trust. The trust tells me that its key workforce challenge remains recruiting registered nurses and junior doctors in training. Those staff shortages lead to expensive cover being required— a bill that is ultimately paid by the taxpayer.
I am pleased that the trust has taken steps to mitigate against staffing shortages, including an extensive recruitment programme where vacancies across the trust are advertised and marketed widely. It has introduced a new associate nurse role in partnership with a local university, and expanded and increased the number of apprenticeship opportunities to offer different routes into careers in the NHS. It has held open theatre days to promote particularly difficult roles to recruit for, such as operating department practitioners. Finally, it has increased the number of nurses and doctors on the local temporary staff bank, which reduces its reliance on, and the cost of, commercial agency staff. I am sure that all hon. Members agree that that is all great.
Despite that work, problems remain. I must put on record my concern that staffing shortages can lead to problems for patients. The ambulatory emergency care unit at Dewsbury and District Hospital opened in 2015 to care for patients who needed a quick diagnosis and treatment, and who could be treated without the need for admission to a hospital bed. Since July, it has been closed because of staff shortages and it will remain closed for the foreseeable future. It had also been closed from the end of December last year to early March. Patients now face the lengthy and expensive trip to Pinderfields Hospital.
In the most recent inspection at Mid Yorks, the results of which were announced last week, the safety of services was deemed to require improvement, which will cause deep concern to my constituents. We are now told that the harsh funding climate for our NHS, which has existed since 2010, is coming to an end—austerity is over.
Stephanie Peacock (Barnsley East) (Lab)
As the daughter of a nurse, I congratulate my hon. Friend on securing this important debate. I know she is a proud member of the GMB, like me, so I declare an interest in highlighting its survey, which showed that 78% of NHS and ambulance workers are incredibly concerned about staffing levels. Does she agree with a nurse from Barnsley who said that we need more registered nurses and trained support staff, not untrained volunteers, who are sometimes being used?
Tracy Brabin
My sister is also a nurse. When someone has a nurse in the family, they understand how hard they work. My hon. Friend must be psychic, because I am about to go on to that point.
When it comes to the recruitment and retention of NHS staff, it could not be further from the truth that austerity is over. The Royal College of Nursing did not mince its words when it said:
“The UK is experiencing a nursing workforce crisis”,
particularly in England. With one in three nurses due to retire within a decade, we are looking at a perfect storm of increasing vacancies across health and care.
Paula Sherriff
Does my hon. Friend share my concern that, as a direct result of staffing shortages at Dewsbury and District Hospital, the midwife-led birthing unit has had to be closed several times? September was a particularly bad month for closures. That has a traumatic effect on mums-to-be, who expect to give birth there but turn up and get sent elsewhere.
Tracy Brabin
Capacity, particularly in midwifery, is a massive issue, and midwife recruitment is also a problem. A mum who is about to have a baby wants to make sure that they are guaranteed a bed and a midwife who will be with them throughout the process, so of course that is a concern. There are almost 41,000 vacant nursing posts in the NHS and it is estimated that that number will grow to almost 48,000 by 2023—just five short years away.
Tim Farron (Westmorland and Lonsdale) (LD)
The hon. Lady is being generous. Does she agree that the problem with the recruitment and retention of staff also stretches to our mental health services? In Cumbria, three years ago, the Government promised a specialist one-to-one eating disorder service for young people, which has yet to be delivered. Does she agree that it is not good enough for the Government to make promises that they cannot deliver because they cannot recruit the staff?
Tracy Brabin
We are seeing increasing problems around recruitment and retention in mental health services, which I will go on to. We know that nurses are heroes of our health service and that they will always voice their concerns.
A survey conducted by the RCN in 2017 had some deeply worrying results. More than half of the nurses said that care was compromised on the last shift and more than 40% said that no action was taken when they raised concerns about staffing. If there was any doubt about the commitment of nurses, nine in 10 were not paid for extra unplanned time worked in the NHS. Unpaid time worked by nurses in the NHS saves the NHS hundreds of millions of pounds a year.
I am not just talking about nurses and the worryingly low levels of recruitment. The Royal College of Physicians informs me that in Yorkshire and Humber 36% of physician consultant posts advertised were not filled. Across the UK, a total of 45% of advertised consultant posts went unfilled, due to the lack of suitable applicants. The RCP believes that we need to double the medical school places to 15,000 a year to alleviate this problem in the long term and it is seriously hard to disagree with that assessment.
The RCP is also calling for investment in public health initiatives, which I am sure is another thing that we all agree on. The desperate need for more mental health staff is well reported. The consultant psychiatrist vacancy rate in the northern and Yorkshire region, which Batley and Spen falls under, is 11.7%, which is higher than the average consultant psychiatry vacancy rate in England. One in 10 consultant psychiatrist posts are vacant. Doctors specialising in mental health are uniquely placed to look at a person’s brain, body and psyche. Such specialists will only become more important, so I ask the Minister to update Members on his plans to meet the target of 570 junior doctors specialising in psychiatry by 2020-21 and to say what plans he has to ensure that all trainee doctors have experience of working in psychiatric settings?
The British Medical Association has provided information on the potential impact of Brexit on staffing levels in the NHS. Nearly 10% of doctors working in the UK are from the European economic area. Doctors, as well as many other professionals, make a massive contribution to our NHS. However, the BMA warns that many EEA doctors continue to feel unwelcome and uncertain about their future here. Given the uncertainty that we have seen in the past few days, I imagine that that feeling will not change any time soon. The results could be devastating, with more than a third of doctors from the EU considering moving away from our country. That is the last thing we need, as hospitals are already chronically understaffed, with more than one in four respondents to a BMA survey reporting that rota gaps are so serious and frequent that they cause significant problems for patient safety.
Alarmingly, some doctors feel bullied into taking on extra work. It is clear that something needs to change, particularly now we are in winter again. There are too few staff, who are too stretched, and trusts across the country are struggling to fill vacancies. However, in order to fix a problem, we need to know whose remit it is to provide a solution. Shockingly, there are no specific legal duties or responsibilities at UK Government level to ensure that health and social care providers have enough staff to provide safe and effective care to meet the needs of the population. Health Education England has some powers related to the higher education supply. In practice, however, those powers relate only to the funding for the 50% of their courses that nursing students spend on placements. Health Education England no longer commissions higher education university places, meaning that it is responsive to students signing up for nursing courses rather than proactively seeking them based on areas of need and workforce planning.
We know that the number of European workers in the NHS has fallen dramatically since the referendum. Mid Yorks recruited highly skilled workers from the Philippines, but delays to visa applications meant that 50% of them have now gone elsewhere and into other jobs. We need to do better than that.
The case is clear to me and to many others that we need a proactive and accountable power-holding body that makes robust assessments of population need, and uses that need to calculate the workforce requirements. No action has been taken to assess the level of population need for health and social care support now or in the future. Nobody has calculated how many nurses are needed to meet those needs safely and effectively. No workforce strategy is in place to set up the mechanism through which new registered nurses can be generated through a supply line.
Workforce plans are not consistently available and when they are they are based on affordability and finance, rather than on the expertise and skills mix of staff required to care for patients. Plans are limited in their ability to make effective change. Providers may identify a need for more nursing posts but then find themselves unable to fill them. Vacant posts stay vacant and gaps on the frontline are filled by more expensive bank and agency staff, and—as we heard from my hon. Friend the Member for Barnsley East (Stephanie Peacock)—by volunteers, or substituted lower-qualified staff. Patient care is left undone, with lengthening waiting lists.
That is the sad truth of where we are and when the Minister responds I would be grateful to know what plans are in place to enforce accountability for the NHS workforce. Simon Stevens has confirmed that the long-term plan for the NHS could not definitely deal with the NHS workforce and there are serious concerns that without investment a new plan will ultimately fail.
Six years on from the Health and Social Care Act 2012, it is still unclear which organisation is accountable for workforce strategy. Too often, no one is taking responsibility. Health Education England has been consulted, but it has failed to deliver a workforce strategy. Now is the time for leadership and action, and I look forward to hearing from the Minister.
Several hon. Members rose—
Mr Philip Hollobone (in the Chair)
Order. The debate can last until 5.30 pm. I have to call the Front Benchers no later than 5.7 pm. Four Members are seeking to catch my eye. The guideline limits for the Front Benchers’ speeches are five minutes for the Scottish National party, five minutes for Her Majesty’s Opposition and 10 minutes for the Minister, and then Tracy Brabin will have two or three minutes at the end of the debate to sum it up. There are 20 minutes of Back-Bench time before I call the Front Benchers, so there will have to be a five-minute time limit on Back Benchers’ contributions.
Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)
I congratulate the hon. Member for Batley and Spen (Tracy Brabin) on securing this debate and on highlighting the biggest challenge facing the NHS: the creeping workforce crisis that has been evolving for some time now. We are now seeing that crisis beginning, in real terms, to affect patient care.
The hon. Lady was right to highlight the fact that a lack of staff in some parts of the country means that operations are being cancelled and beds are being closed. She was also right to point out the challenges that Brexit poses to the recruitment and retention of frontline NHS staff; in the past decade, we have been increasingly reliant on European Union staff coming to work in the UK—before that, it was staff from outside the EU who provided most of the overseas workforce in the NHS. I am sure that all of us would like to put on the record our support for the excellent work that NHS staff from the UK and from all over the world do in caring for patients.
I will also do what I should have done at the beginning of my speech and draw attention to my declaration in the Register of Members’ Financial Interests, as I am a practising NHS hospital doctor working in mental health services.
Dr Poulter
I will not, because of the time limit and because I want to let other people speak; I am sure that we can talk about this issue in detail after the debate.
Very briefly, Mr Hollobone, the Government have made a number of promises about NHS staffing and yet, unfortunately, those promises are failing to come to fruition. In 2015, there was a promise of 5,000 more GPs. Recently, I submitted a written parliamentary question about how much progress had been made in realising that target but I did not get an adequate answer. I would be grateful if the Minister updated us in his concluding remarks by saying how close we are to realising that target of 5,000 additional full-time GPs.
I would also like to highlight some of the challenges in community and mental health services. Very often in this Chamber, we talk about hospitals, and very often the NHS is seen through the prism of that acute sector, but the key challenge to keeping people out of hospital is doing more in the community, building up community mental and physical health services—and they are the very services that are seeing reductions in frontline staff.
I want to touch briefly on mental health. We know that the number of full-time-equivalent mental health nurses fell by 6,000 between 2010 and March 2018, including a reduction of more than 1,800 in learning disability nurses alone. The number of child and adolescent mental health service and learning disability consultant psychiatrists has also slightly declined over the past decade, and many parts of the country, particularly outside London, are struggling to fill higher registrar training posts in those services.
Perhaps more concerning is that the number of junior doctors in specialist psychiatry training—core and higher psychiatric trainees who will become the consultant psychiatrists of tomorrow—has also fallen, by 490 full-time equivalent doctors, from 3,187 in 2009 to 2,697 in March 2018. [Interruption.] The civil servants are rapidly checking my figures; they are from answers to parliamentary questions, so they are absolutely correct.
That is a woeful record of decline in the psychiatric and mental health workforce, and it must be corrected. If the Government are serious about their rhetoric on mental health, about improving the quality of provision for people with poor mental health, they need to recognise that the workforce has already declined. Even if there is the promised increase in numbers, it will be from a lower baseline than that of about a decade ago.
The only way to deliver the expansion in services that patients deserve—for example, specialist eating disorder services in Cumbria or East Anglia—is by having a much more serious approach to the recruitment and retention of mental health staff and by paying premiums to attract both doctors to work in CAMHS and people to work in parts of the country where there is a shortage of mental health staff. I look forward to the Minister’s response.
Rachael Maskell (York Central) (Lab/Co-op)
I congratulate my hon. Friend the Member for Batley and Spen (Tracy Brabin) on calling this vital debate.
I remember the challenging years of the mid-1990s, when I was working as a physio in the NHS. During that crisis time, I never knew when I would get home. Today’s scenario reminds me of the dying years of a Tory Government—the parallels are so strong.
In York, I read the Care Quality Commission reports in detail, and although the care given by our NHS staff is excellent, the real challenge that I pull out of the results of CQC reports is the staffing crisis. My local hospital currently has 59 doctor vacancies, and there are 580 nursing vacancies in bands 4 to 7, 312 of which are in bands 5 to 7. The trust has done everything it can to recruit. It went to Spain and recruited 40 Spanish nurses, 37 of whom left after a very short period. The reality is that NHS staffing is in crisis and that affects patient care.
Last year, the trust had to spend £8.5 million on agency staff. That pushed a trust that is already struggling because the funding formula does not work for York into further deficit, which has an impact on its control and on the resources it can get for the winter crisis—York had some of the highest levels of influenza last year. The Minister, therefore, must ensure that the money works, as well as addressing staffing.
I want briefly to look at primary care because, as we have heard, we need early intervention across all ages to keep people out of hospital. Rightly, the Government looked to increase the number of health visitors, and by 2015 the figure was up to 10,309, but since then we have seen a 23.8% fall, down to 7,852, meaning that young people are not getting the input they need. School nursing figures have also fallen by 25% since 2010. So we have a real crisis in our primary care workforce, and also in mental health, as the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) said. Certainly we feel that in York, whether in the community or the hospital environment.
Rachael Maskell
I am going to continue.
The trust is doing everything it can to recruit, but it is impossible to recruit because the national pool of mental health staff is far too small. Therefore, it is vital that we consider the solution, which comes down, as has been said, to workforce planning. We need a partnership approach to planning the workforce. We need to understand the changing demographics and the increasing mental health challenges in order to put the right planning in place, but trusts will not be able to recruit unless the staffing framework is right. The removal of the bursary scheme has been seriously detrimental, particularly to the recruitment of mature students into nursing. People are giving up a job, but their staying in the profession for longer will pay dividends. Students have to pay to travel to placements, and I remember what that was like, so it is really important that they have bursaries.
Secondly on workforce planning, we need to look at how we educate healthcare professionals across the board. I remember discussions at a national level with the trade unions on that very issue, about needing to find a different way. In some countries they bring a real foundation into NHS training so that everyone works together in the first 18 months or two years of their training and has a breadth of understanding of medicine before going off to specialise. We, instead, train in traditional old silos of jobs that have clearly blended over the years, and we must look once again at how we structure that.
Thirdly, we need to look at the “Agenda for Change” package. There is no doubt that it is hard to recruit because people are poorly paid in the NHS and can be better paid elsewhere. Given the stress levels and the antisocial hours that people work, we need to look once again at the remuneration of our NHS workforce. Finally, the knowledge and skills framework has consistently been underutilised by the Government and NHS employers, and it is vital that we go back to that framework of professional development in the NHS.
Maria Caulfield (Lewes) (Con)
I declare my interest as a nurse who is still on the Nursing and Midwifery Council, or NMC, register. I speak, therefore, with first- hand experience about having to deal with staffing shortages during more than 20 years of working in the NHS. Staffing problems have always been there, but I welcome the debate that the hon. Member for Batley and Spen (Tracy Brabin) has secured because we must recognise the issues that many hospital trusts and community services are experiencing.
I welcome last month’s NMC figures, which show an increase of more than 4,000 nurses joining the register in the past 12 months, a significant percentage of whom were UK-trained nurses. There was also an increase of 3,000 UK nurses compared with this time last year. I welcome those figures, but that is not to say that there is not a staffing problem across the NHS.
I want to focus on some of the solutions from my experience that would make a real difference out there in the workforce. I understand the sentiments of the hon. Members for Batley and Spen and for York Central (Rachael Maskell) about the bursary scheme, but I trained on that scheme myself and it is far from the panacea that has been portrayed in recent years. We were paid a pittance—£400 a month—for the three years of our training. Yes, it paid for travel and expenses, but not for much else.
Someone training as a nurse has to do the minimum hours to get on to the register, so it is very difficult for them to have an additional job, as other students would. Often times they are mature students and have other commitments, such as children and family responsibilities, and an additional part-time job is almost impossible to hold down. Life on a bursary was tough, and it often explained the high drop-out rate during the three years.
The system I would prefer, and have always advocated, is the degree apprenticeship route. During my time in this place, I have been doing bank shifts at my old hospital with student nurses who are now on the degree apprenticeship route: it is a far better system, and we need to upscale it as a matter of course. Not only are student nurses earning while they are learning; they are part of the workforce, which is a point that the bursary scheme missed completely. Student nurses were university students, but not necessarily part of the working environment, and often found it tough to move into that environment, because they were not seen as key members of the workforce.
The degree apprenticeship route also means that when students work for hospitals or community trusts during their degree apprenticeship, they are often being paid by those trusts, which are then able to accurately predict the number of students coming through the system. That was different under the bursary system: trusts just had to wait and see which newly qualified nurses applied for their vacant posts. For long-term workforce planning, having those student nurses as part of the team means that trusts have an idea of who is likely to come forward when they qualify. There are a number of positives, and I push for the Government to roll out that degree apprenticeship system—maybe not just in nursing, but in other healthcare professional specialities.
I will briefly touch on flexible working. We are under the misapprehension that internal rotation and a shift-based system means there is flexible working for staff in the NHS, which there absolutely is not. In most areas, people are forced to do internal rotation, whether in the community or in the hospital-based system, and that is increasing as we move towards a seven-day-a-week service. If young parents with children are all of a sudden put on a week of nights with a week’s notice, and have no childcare provision, that makes it almost impossible for them to hold down their job.
In the good old days when I first started, people were able to do a permanent nights system, to do permanent weekends, or to choose to work evening shifts. That is all gone now: they are forced to do internal rotation. I say to the Minister that the NHS needs to look at a flexible working system for its staff, because if it does, it is more likely to hold on to the excellent staff who keep the NHS going.
Rachel Maclean (Redditch) (Con)
It is a pleasure to serve under your chairmanship, Mr Hollobone, and I congratulate the hon. Member for Batley and Spen (Tracy Brabin) on having secured this important debate. I have a little bit of a family connection to the NHS, as I am the daughter of a GP, but it is an honour to follow colleagues of all parties who have direct experience of working in the NHS. I welcome their having shared that experience with us.
Staffing levels in the NHS are an important issue, which affects my local NHS trust in Worcestershire as well. I am in close contact with that trust and with staff at the Alexandra hospital in Redditch, and I very much hear that concern; I hear it from my constituents all the time. I agree that it is essential that we increase the NHS workforce at all levels, from nurses to consultants and, particularly, GPs. We are now in a situation in which demand is rising fast: the population is growing, it is ageing, and people are living longer. That is partly due to the success of our fantastic NHS, and the doctors and nurses who work within it, but it does create one of the biggest problems that the NHS faces.
I must have met every Minister in the Department of Health and Social Care over the past few months, and I am looking forward to meeting the Secretary of State later today, when I will be pressing for more details about a welcome capital investment in breast cancer services at the Alexandra hospital and across Worcestershire. There has also been more investment in my local hospital, to keep the frailty unit open and open a new urgent care centre. However, all those services have to be staffed, and we need the stability and security of knowing they will continue to be there, serving my constituents. I welcome those changes, but in previous meetings, I have consistently pressed the issue of staffing levels. I am encouraged that the Government are focused on meeting these challenges and providing the NHS with the workforce we need it to have.
At the moment, one of the biggest recruitment drives in the NHS’s history is taking place. It is intended to increase the number of doctors and nurses trained in the NHS by 25%—an increase of 1,500 places a year. Steps such as those will play a crucial role in supporting the future NHS workforce, but as Members have highlighted, the immediate pressures are still here and must be addressed now. Nowhere is this issue more acute than in general practice, and I often write to constituents who have complained about the waiting times for seeing their GP. Since becoming the MP for Redditch in 2017, I have pushed for change; I am pleased that the Government are listening and now intend to hire 5,000 more GPs and 5,000 additional GP staff by 2020.
I also welcome the fact that the Home Office has exempted doctors and nurses from the tier 2 visa quota system for non-EEA skilled migrant workers. That will enable the NHS to recruit more quickly and widely, especially considering that NHS recruitment demands account for 40% of tier 2 places. I welcome the fact that the Prime Minister and the Secretary of State for Health and Social Care have said time and again that we must get the message out that we want EU nationals to stay in this country, and we need them in our NHS. That has been unilaterally guaranteed by this country, with or without a deal, so please let us get that message out to our wonderful NHS staff.
There are positive steps, and the progress that has already been made should be welcomed. In my county of Worcestershire, the total number of staff employed rose by almost 7% between August 2013 and August of this year, to over 5,000. [Interruption.]
Rachel Maclean
I believe I was noting the positive progress in Worcestershire. The total number of staff employed rose by 7% to more than 5,000 between August 2013 and August this year, and the number of doctors has increased by 5% . The number of nurses has gone up by nearly 8%. There are now nearly 1,400 nurses working in Worcestershire acute hospitals. I have been to the wards, and spoken to the nurses at the Alex who tell me about the positive recruitment days that they have held at the University of Worcestershire. I very much welcome that work, and I hope that it will continue to bear fruit.
It is vital to maintain the morale of our staff, and I welcome what my hon. Friend the Member for Lewes (Maria Caulfield) said regarding flexible working. It is important that we look at the issues in the round. As a former employer myself, I know how important it is to get every aspect of the employment offer right. I welcome the new contract deals that will result in a 6.5% pay rise for more than 1 million NHS workers this year. That means that those on the lowest salaries in the NHS will see some of the largest proportionate pay rises. Many nurses and healthcare assistants will enjoy pay increases of at least 25%. We must get the pay offer right to ensure that we encourage our NHS staff both to enter the profession and to stay.
I thank the Minister for attending the debate. I want to hear more about the strategy. I welcome the progress that has been made, and I implore him to continue, steadfast, in that pursuit.
Dr Philippa Whitford (Central Ayrshire) (SNP)
It is an honour to serve under your chairmanship, Mr Hollobone. I, too, declare an interest as a longstanding NHS worker of more than 30 years.
Healthcare is not delivered by machines or buildings; it is delivered by people. People are the core of the NHS. The problem relates to workforce, and it is hitting all four nations. Although Scotland has the highest ratio of every group of healthcare staff per head of population, we too face challenges. We have a 4.8% nurse vacancy rate in Scotland, but in England it is more than 11.5%. The Royal College of Nursing says that there are 41,000 nurse vacancies at the moment, and if action is not taken, that will rise to 48,000.
As other Members mentioned, since the introduction of the bursary in 2015, there has been a one third drop in applications. Acceptances in England have gone down by almost 4%, whereas in Scotland they have gone up by almost 14.5% over the same period. The bursary is having a huge impact, particularly on mature students, who might already have a degree and have therefore also been hit by the removal of the post graduate bursary that allows a nurse to be trained in just two years.
There has been a 15% drop in mature students, which is hitting those with mental health issues and learning disabilities in particular, as those specialities tend to attract the more mature nurse student. There has been a 13% drop in mental health nursing staff and a 40% drop in nurses looking after those with learning disabilities. That makes those services unsustainable.
Brexit is affecting the workforce, as it is every other aspect of life. There has been a 90% drop in European nurses registering to come and work in the UK, and a trebling of EU nurses who are leaving the UK register. That does not help to solve the problem, and those nurses cannot be totally replaced by UK staff in enough time. It does not matter that the Government come out with warm words if the Home Office’s actions make people feel insecure. Friends of ours who have been GPs for more than 20 years in Scotland applied for citizenship for their children. The eldest and youngest children were granted it; the middle child was refused. What are they now talking about? “Maybe we should go back to Germany where we’d be safe.”
From every angle, the Government are taking actions that are making staffing levels worse. The former Secretary of State for Health, the right hon. Member for South West Surrey (Mr Hunt), used to go on about the lack of junior doctors and consultants as a cause of excess deaths among those admitted at weekends. Actually, the only staffing impact proven through research is on the ratio of registered nurses to patients—not healthcare assistants or others.
Dr Poulter
I am sure that most of us had great concerns about the previous Secretary of State’s use of statistics, but a mental health study was carried out and the highest morbidity rates were in the middle of the week, not at weekends, which rather disproved the assertions that he was making.
Dr Whitford
We pointed that out repeatedly at the time. It has been shown time and again that quality, well-trained, experienced nurses—not so much agency nurses or healthcare assistants—who know a ward are the bedrock of every single service in healthcare.
Brexit is having an impact. Even though in Scotland our Government have promised to pay settled status fees for all those working in public services, we have already lost, according to the British Medical Association survey, 14% of our doctors. England has lost almost 20%. We cannot reach a point where England has 50,000 nurse vacancies. That would be unsafe. The Government need to take action and, like the Scottish Government, put the bursary back, get rid of tuition fees, and make it sustainable for people to train to become nurses. If they do not do that, the sustainability and safety of the NHS in England will deteriorate further.
Justin Madders (Ellesmere Port and Neston) (Lab)
It is a pleasure to serve under your chairmanship, Mr Hollobone. I congratulate my hon. Friend the Member for Batley and Spen (Tracy Brabin) on securing this extremely important debate, and on the tour de force that she presented. She touched on many important issues. Time restrains me, so I will not be able to pick up on all the points that she made, nor on all the impressive contributions made by other Members, particularly those who have had frontline experience, and had practical examples that we need to look into further.
My hon. Friend talked about her local trust being a big employer in her constituency and beyond. Indeed, it employs some 8,000 people, but has a 10% vacancy rate—sadly, very much in line with the national average. She was right that covering the gaps in the rota is an expensive business. I was pleased to hear that so many initiatives were being undertaken by the trust, but the fact that there is still a 10% vacancy rate shows that something is broken with the system.
My hon. Friend highlighted the impact on patients that staff shortages can have regarding closures, and she was right to highlight the nursing workforce crisis and the whole range of specialisms that are at risk. She was also right to raise the uncertainty that Brexit brings to staff, and to highlight the lack of legal powers to require safe staffing levels, and the overall strategy that we need to get the correct staffing levels.
I was also delighted, as always, to hear from my hon. Friend the Member for York Central (Rachael Maskell). She was right that agency spend sucks away vital resources and that recruitment challenges will never be solved unless we get the right framework. That is why we deeply regret the abolition of the nurse bursary, to which I will return.
We know that the NHS workforce is extraordinary. The NHS is one of the biggest employers in the world, and we must pay tribute, as we do every time, to the staff who work so tirelessly, day in and day out. We also have to recognise that there are simply not enough of them. Last month, the King’s Fund, the Nuffield Trust and the Health Foundation joined forces and warned that the staffing crisis in the NHS is deepening so fast that the service could be short of up to 350,000 staff by 2030. That warning is stark. Clearly there is an existential threat to the NHS if action is not taken to address the staffing crisis that we are now being told about.
According to official figures, there were more than 102,000 vacancies across the NHS at the end of September. That means that one in 11 posts in the NHS is currently vacant. The chair of NHS Improvement, Baroness Harding, recently acknowledged that
“the single biggest problem in the NHS at the moment is that we don’t have enough people wanting to work in it.”
However, the issues that we face run far deeper than merely how attractive the profession looks to applicants.
As my hon. Friend the Member for Batley and Spen said, we face a perfect storm of a retention crisis caused by factors including pay and conditions, ongoing uncertainty about Brexit, demographic challenges in many sectors of the workforce and the ongoing impact of the catastrophic decision to scrap bursaries for nurses, midwives and allied health professionals. Although many of those issues are clear and long-standing, there is no credible overarching strategy to address any of them. As the House of Lords Select Committee on the Long-term Sustainability of the NHS found, the lack of such a strategy
“represents the biggest internal threat to the sustainability of the NHS.”
We all eagerly await the publication of the NHS long-term plan, but I would welcome the Minister’s confirmation of precisely when that will happen. I was deeply concerned to hear Simon Stevens’s comments about how the plan will not definitively address staffing problems. Will the Minister confirm whether that is the case? If so, when will we see the comprehensive strategy for the NHS workforce that we so desperately need?
As many hon. Members have said, the workforce crisis has been compounded by the abolition of undergraduate nurse bursaries. When it was announced that bursaries would be abolished, we were told that our many concerns were misguided and that the changes would lead to an additional 10,000 training places being provided. However, just as everyone but the Government predicted, the exact opposite has happened. As of September 2018, almost 1,800 fewer people are due to start university nursing courses in England, while the number of mature students has plummeted by 15%.
In our debate on nursing higher education on 21 November, the Minister said:
“We expect NHS England to clearly set out its commitment to the nursing workforce in the long-term plan, and ensure that there is a clear way for that plan to be implemented…The Government will be consulting on the detailed proposals on future funding for higher education that the RCN has put forward”.—[Official Report, 21 November 2018; Vol. 649, c. 372WH.]
Will he provide greater detail on that point and say when that consultation will take place?
The issues that hon. Members have discussed today are acute, systemic and entrenched, but they have been exacerbated by the Government’s short-term and flawed approach. Any long-term strategy for the NHS will fail if it does not address them. Staff and patients deserve more than a health service in a constant state of crisis. They deserve better than this Government.
The Minister for Health (Stephen Hammond)
It is a pleasure to serve under your chairmanship, Mr Hollobone. I thank the hon. Member for Batley and Spen (Tracy Brabin) for securing this debate. As she and hon. Members who have contributed to other such debates will know, the issues she raises are very similar to those that we discussed on 21 November in the debate that the hon. Member for Ellesmere Port and Neston (Justin Madders) has just referred to. However, it is welcome to have the opportunity to discuss them again, because such debates reflect the importance that we all place on the NHS workforce. The one thing that the hon. Gentleman and I agree on is that it is right to begin by reiterating our thanks to the NHS professional staff for their work treating patients day in, day out.
I also thank other hon. Members for their contributions. I note in particular the comment rightly made by my hon. Friend the Member for Lewes (Maria Caulfield) that we need to upscale nurse degree apprenticeship routes. I will speak about that in more detail if I have time. My hon. Friend the Member for Redditch (Rachel Maclean) spoke about the capital announcement made last week, which I was pleased to see come through. My hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter) made some points about mental health—may I offer him a meeting at the Department to discuss those matters directly, because today I want to concentrate on other matters? The hon. Member for York Central (Rachael Maskell) made a contribution based on her valuable experience.
I should say right at the outset, as I did in our debate two weeks ago, that the Government greatly value the staff who contribute to and support the NHS. We understand its importance and are committed to ensuring that it is supported and funded appropriately, which is clearly reflected in the extra £20.5 billion a year that the NHS will get by 2023-24.
As the hon. Member for Ellesmere Port and Neston quoted me saying in our last debate, we expect NHS England to set out clearly its commitment to the workforce in the long-term plan. The plan will address how to open up the profession to more people from all backgrounds and ensure that they get the right support throughout their training. To answer his question: yes, when the long-term plan is published, he will see the workforce embedded in it and in our strategy. We also expect NHS England to deliver a clear implementation plan to guarantee the future of the workforce. The NHS employs a record number of staff—more than 1.2 million in 2018, which is more than at any other time in its 70-year history—with significant growth in newly qualified staff since 2010.
Let me repeat what I said two weeks ago:
“the Government, and I as the new Minister for Health, should never be complacent”.—[Official Report, 21 November 2018; Vol. 649, c. 372WH.]
We are not. We are absolutely committed to ensuring that nursing remains an attractive career so that the NHS can build on the record numbers of nurses on our wards. Actions already taken to boost the supply of nurses range from training more nurses and offering new routes into the profession to enhancing rewards and pay packages, and there are now 11,000 more nurses on our wards than in May 2010.
NHS England, NHS Improvement and Health Education England are working with trusts on a range of recruitment, retention and return to practice programmes to ensure that the required workforce is in place to deliver safe and effective services. We should note that NHS Improvement has had some real success with its retention programme. Retention seems to me one of the key issues for the Government to focus on, and that will be reflected in the long-term plan. NHS Improvement’s programme continues its direct work with trusts to support improvements in retention, with a focus on the nursing workforce and the mental health clinical workforce. So far, 35 trusts have been involved and the initial evidence is positive and encouraging, with more flexible working programmes and greater support for older workers. It is therefore right that that programme be expanded further to all remaining NHS trusts in England.
Maria Caulfield
Revalidation is a new system for nurses to retain their registration, but it is a very difficult and stressful process for nurses who may be part-time or part of a hospital bank. I was lucky because my NHS trust, the Royal Marsden, is extremely supportive to its bank workers, but will the Minister ensure that bank nurses are supported through the revalidation process to keep them registered?
Stephen Hammond
I am listening carefully to my hon. Friend, and I will ensure that that work is undertaken.
As I have said today and on previous occasions, the priority is to get more nurses on our wards. There are currently 52,000 nurses in training, and we have announced a policy change that will result in additional clinical placement funding to make 5,000 more training places available each year. My hon. Friend made the point that nursing bursaries were not always the panacea that everyone suggests; students on the loans system are at least 25% better off than under the previous system. However, we recognise that students incur additional costs as a result of attending clinical placements, so we have introduced a learning support fund with a child dependants allowance, reimbursement of travel costs and an exceptional hardship fund. When I spoke to nurses at Barts last week, I listened carefully to the points they made about the need for help with travel in particular, and I am looking carefully at that issue.
The hon. Member for Batley and Spen raised the RCN proposal. Yesterday, as I had promised I would, I responded to the RCN in a formal letter to Dame Donna, and I look forward to meeting her to discuss her proposals in the near future—hopefully the very near future.
We are increasing the number of midwifery training places by more than 3,000 over the next four years. There continues to be strong demand for nursing places, with more applicants than places, but I am under no illusions, nor am I complacent. We need more people applying and we need to increase that route. A number of routes are open. HEE’s programme covers all fields of nursing; its RePAIR—reducing pre-registration attrition and improving retention—programme explores effective interventions to ensure that people are supported through their whole student journey from pre-enrolment to post-qualification.
The hon. Member for Batley and Spen was right to mention the number of new routes into nursing. In particular, she will have noted the report published last week by the Select Committee on Education on the nurse degree apprenticeship. We are working with the Department for Education to carefully consider the Committee’s recommendations and I will respond in due course.
I want to turn to the story of doctors. In the NHS today, it is true that there are 18,200 more doctors in trusts and CCGs than there were in 2010. My hon. Friend the Member for Central Suffolk and North Ipswich raised the matter of the additional 5,000 doctors. This year, we have recruited 3,473 GP trainees, against the target of 3,250. That is an increase on last year, but we are determined to meet the commitment of 5,000. To ensure that that is possible, we have rolled out an extra 1,500 medical school places. By 2020, as he knows, five new medical schools will be open to deliver that expansion.
In the whole of this discussion, it is only right that I recognise that the Government value the professionals. It is key that we ensure that NHS staff are well remunerated. It is absolutely right that we have given NHS staff a well-deserved pay rise. All staff will receive a 3% pay rise by the end of 2018-19.
There is a lot more I might have said. The hon. Member for Batley and Spen raised a number of local issues, including ambulatory care. If she cares to write to me or to catch me, I would be happy to have a longer discussion with her. I thank her and all hon. Members for the points they have made in the debate. I also stress, as I have done today to staff at North Middlesex, and last week, that making sure that we have an NHS long-term plan that sets out a strategy for the NHS and ensures a sustainable supply of clinical workforce—doctors, workers and others—is key, and it is key to delivering our ambitions for the NHS. I thank the staff for all that they do.
Tracy Brabin
I thank colleagues from both sides of the House for their contributions, particularly those with frontline experience, and I thank the Minister for his measured response.
I have a couple of points. First, I am sure the Minister can feel the sense of urgency in this debate. Although I appreciate that long-term discussions are needed, we still do not have a date for when the long-term plan will be published or for the consultation on the Royal College of Nursing proposals. The Minister said it would be soon, but when will we have that?
Stephen Hammond
There is a commitment from the Government to produce the long-term plan before the end of the year, as the hon. Lady knows, and I have written to Dame Donna to request a meeting to discuss the RCN’s proposals.
Tracy Brabin
That is very reassuring.
We hear from across the House that mental health is receiving such little support. People are hanging by a thread. Nurses are saying to their organisations and their MPs, “I am worried for the health and safety of my patients. I’m doing too many shifts. I’m absolutely shattered. I can’t guarantee that I am going to be doing my job properly. They’re bringing in volunteers to support me on the ward.” It is an absolute crisis. While I understand that the wheels of government work very slowly, I hope that the Minister takes from this debate that Brexit has been a universal issue. We are losing staff members. I welcome the commitment to an extra 5,000 doctors and so on, but that is just plugging the gap of the staff who are draining away from our hospitals and frontline services.
Stephen Hammond
I absolutely recognise that Brexit is a pressure on the system, but we should also recognise that there are 4,367 more professionals working in the NHS from the EU than there were at the date of the referendum. It is important to put that on the record.
Tracy Brabin
If that is the case, the statistics are welcome, but in my constituency we are losing European members of staff. We cannot get away from the overall numbers—there are staffing shortages of 10%. In my constituency and in my trust they cannot recruit, because of various issues. I am grateful that the Government listened when I raised the question of tier 2 visas with the Prime Minister, when we wanted to bring over a paediatrician but could not because the visa took so long that he got another job. I welcome that when it comes to nurses, too, but we have to accept that there are things such as the bursary—