Tuesday 21st September 2021
(3 years, 2 months ago)
Public Bill CommitteesHealth and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Amendment Paper: Public Bill Committee Amendments as at 21 September 2021 - (21 Sep 2021)
The Committee divided: - Ayes: 5 / Noes: 9 - Question accordingly negatived.
The Committee divided: - Ayes: 5 / Noes: 9 - Question accordingly negatived.
The Chair
With this it will be convenient to consider:
Government amendment 14.
That schedule 4 be the Fourth schedule to the Bill.
The Minister for Health (Edward Argar)
Mrs Murray, it is—even more than usual—a pleasure to serve under your chairmanship: I am still standing before you in this Committee and opposite the hon. Member for Ellesmere Port and Neston, as seems to be our fate. He has served in his Front-Bench role longer than I have in mine, and that is going some.
Clause 25 gives effect to schedule 4, which contains minor and consequential amendments relating to the introduction of integrated care boards. The majority of the amendments relate to replacing existing references to clinical commissioning groups in legislation with references to integrated care boards. The schedule is necessary to ensure that existing primary legislation that refers to CCGs will continue to operate effectively once ICBs are established. Without it, references to clinical commissioning groups would be erroneous and the new commissioning bodies, ICBs, would not be referenced where they need to be across the statute book.
Following from that, Government amendment 14 is minor and technical. It is simply to ensure that the legislation hangs together properly. It makes no change to the status quo, but reflects that clause 15 of the Bill replaces section 3 of the National Health Service Act 2006 with a slightly amended proposed new section 3. A consequential amendment is therefore needed to section 187 of the 2006 Act so that it refers to the correct subsections. Previously it referenced subsections 3(1)(d) and (e), but those same subsections have now been moved to 3(1)(e) and (f) in proposed new section 3.
The amendment simply updates the cross references in section 187, without which section 187 would refer to incorrect subsections, which could result in regulations made under section 187 allowing for charging for the wrong services. That is, quite clearly, not our intention, and we are simply continuing the status quo and clarifying that matter.
Question put and agreed to.
Clause 25 accordingly ordered to stand part of the Bill.
Schedule 4
Integrated care system: minor and consequential amendments
Amendment made: 14, page 151, line 34 in schedule 4, at end insert—
“107A In section 187 (charges for designated services or facilities), for ‘section 3(1)(d) or (e)’ substitute ‘section 3(1)(e) or (f)’.”—(Edward Argar.)
This amendment is consequential on clause 15 of the Bill, which changes the numbering in section 3(1) of the National Health Service Act 2006.
Schedule 4, as amended, agreed to.
Clause 26
Abolition of Monitor and transfer of functions to NHS England
Question proposed, That the clause stand part of the Bill.
The Chair
With this it will be convenient to discuss the following:
That schedule 5 be the Fifth schedule to the Bill.
Clauses 27 to 32 stand part.
Edward Argar
NHS England and NHS Improvement, comprised of Monitor and the NHS Trust Development Authority—the TDA—requested the primary legislative changes to support the merger of their organisations, and these clauses are fundamental to fulfilling that ambition. In recent years, NHS England and Monitor, as part of NHS Improvement, have been working closely together with a view to acting as a single organisation with a single operating model. They already have aligned board and committee arrangements and joint senior executive appointments through the joint working programme. Despite the progress made, there are limits to the extent to which they can collaborate under the current statutory framework.
Establishing a single statutory body responsible for the health care system in England has several clear benefits. First, it will create a more joined-up approach across the NHS to provide national leadership and speak with one voice to set clear and consistent expectations for providers, commissioners and local health systems. Secondly, it brings services, support and improvement under a single regulatory and legislative framework. That will deliver improved care for patients, enabling better use of collective resources, removing unnecessary duplication and ultimately making better use of public money. The merger will provide clearer lines of accountability so that the public can be assured that any service they use meets the same requirements around safety and quality.
Alex Norris (Nottingham North) (Lab/Co-op)
One of the problems that we have found in Nottingham around driving integration was the duplication of lots of different regulators and metrics, which meant that organisations were often working to different purposes. This obviously tidies that up a bit in terms of regulators. Does the Minister envisage going further in the future?
Edward Argar
I am grateful to the shadow Minister for that question, which reminds me of some of the questions that he used to ask me in this room about what the future held when we discussed delegated legislation. I am always cautious not to predict the future, but hopefully it will be helpful if I set out the principles that I think should apply. I agree that unnecessary duplication that does not bring clear and tangible benefits to patient safety or improve outcomes is clearly undesirable. Therefore we will seek to streamline where appropriate, but without compromising patient safety or the outcomes that patients experience. While not predicting the future, I hope that gives him some reassurance of the direction of travel as I see it.
Clause 26, along with other provisions in the Bill, including clause 29, makes the legal changes necessary to bring these organisations together as one legal entity. Clause 26 abolishes Monitor and introduces schedule 5, which contains amendments that transfer Monitor’s functions to NHS England in order to fulfil the Bill’s intention to merge Monitor and the NHS TDA into NHS England to form a single body. The schedule transfers powers and duties from Monitor to NHS England and repeals provisions that are no longer necessary in the light of the merger. For example, Monitor’s functions in relation to NHS foundation trust mergers and acquisitions in sections 56 and 56(a) of the 2006 Act, and in relation to licensing providers in sections 81 to 114 of the Health and Social Care Act 2012, will all transfer to NHS England.
We acknowledge that bringing together the commissioning functions previously exercised by the NHS commissioning board, and the regulatory functions previously exercised by Monitor, under a single organisation could be perceived as giving rise to conflicts of interest. The Bill will therefore ensure the proper management of any such conflicts, and we will work with stakeholders on robust processes that will safeguard the separation of responsibilities and improve transparency. For those reasons, clause 27 seeks to insert new section 13SA, which deals with minimising conflicts between the body’s regulatory and other functions, into the National Health Service Act 2006.
The clause places a duty on NHS England to minimise the risk of conflict or manage any conflicts that arise between its regulatory functions and other functions. In the event that a conflict were to occur, NHS England would be under a duty to resolve or manage that conflict and to ensure appropriate transparency. NHS England must include within its annual report details of such conflicts and how it had complied with its duties to manage them under new section 13SA of the 2006 Act.
Clause 28 amends section 100 of the Health and Social Care Act 2012, which relates to the modification of licence conditions for providers. Licences are the basis by which NHS Improvement and, in future, NHS England set conditions on providers as to the terms on which they can operate. The clause requires that when NHS England makes a major change to the standard licence conditions, as permitted under section 100 of the 2012 Act, it must assess the likely impact of the change or publish a statement explaining why such an assessment is not needed.
The clause also provides that the impact assessment carried out by NHS England must be included in the notice of the modification that is sent to the relevant licence holder and others, as required by section 100(2) of the 2012 Act. This new requirement is intended to make it clearer why NHS England is altering a standard licence condition, which we think is in the interests of providers and the smooth running of the system.
Clause 29 abolishes the NHS TDA and works in harmony with clause 26, which abolishes Monitor and other provisions in the Bill that confer functions on NHS England in relation to providers, in order to merge the two organisations into NHS England to form a single body. In transferring functions that were formerly delegated to the TDA, we have considered the mechanisms and processes associated with those duties and assessed the best fit for the system, to ensure that the relationships already in place are not unduly affected. Clause 29 revokes the directions that established the TDA, and subsections (3) and (4) include consequential amendments that remove references to the TDA. They will no longer be relevant once the TDA is abolished.
Clause 30 makes a consequential amendment to NHS England’s general functions to reflect its oversight of NHS trusts and foundation trusts due to the merger of NHS England and NHS Improvement. The clause ensures a joined-up approach to decision making, allowing NHS England to understand the services required to best serve patients. It amends section 1H of the National Health Service Act 2006 so that for the purpose of discharging its duty to promote a comprehensive health service in England, NHS England must exercise its functions in relation to English NHS trusts and foundation trusts, as well as in relation to ICBs, which will replace the current reference to CCGs, so that services are provided for that purpose.
As part of the merger of NHS England, Monitor and the NHS TDA, and as a consequence of the abolition of Monitor and the NHS Trust Development Authority, clause 31 gives the Secretary of State the power to make schemes to transfer the staff, property, rights and liabilities from Monitor and the TDA to NHS England. These transfer scheme provisions follow a similar protocol used within the Health and Social Care Act 2012 for the transfer of assets, rights or liabilities on the abolition of the National Institute for Clinical Excellence and the Health and Social Care Information Centre. The transfer schemes used then proved effective and efficient, ensuring a smooth transition and no impact on the services they delivered.
Finally, clause 32 contains a regulation-making power that allows the Treasury to vary the way in which any relevant tax has effect in relation to the transfer scheme. Regulations made under this power can be used to ensure that no taxes arise, and that there are no changes to the tax positions of either the transferee or transferor body. It is appropriate to avoid unnecessary tax complications relating to a transfer scheme between public bodies. The types of taxes that can be varied are set out in the clause.
Without this clause, the transfer of assets or liabilities between the bodies mentioned in clause 31—namely Monitor, NHS Trust Development Authority and NHS England—could give rise to unintended tax liabilities. As I have highlighted, this merger has clear benefits and is central to the Government’s plans for establishing a more integrated, responsive and accountable health and care system.
Justin Madders
I am grateful to the Minister for his detail on those clauses, which have been very helpfully grouped. Although we have not put forward any amendments, we do want to raise some general concerns—mostly around what these clauses do not do.
As we have heard—although I do not think the Minister used quite the same terminology as we would have—these clauses have got rid of the worst trappings of the market architecture, which were characteristic of the Lansley Act. As we have heard, they enable the merger of NHS England and NHS Improvement, although I do not think that NHS Improvement is actually mentioned anywhere in the Bill. All references are to Monitor and the NHS Trust Development Authority. It is almost as if the Government want us to forget that NHS Improvement ever existed—or probably want us to forget who was chairing it.
The abolition of Monitor sounds another death knell for the Lansley Act, but does leave some of the market mechanisms in place. However, since they were ignored anyway, I can understand why the Government have not bothered to go the whole hog.
Clause 26 finally turns the Monitor off at the mains—although I think it is fair to say that it stopped working some time ago. NHS England is now the undisputed, supreme leader over commissioning and both flavours of providing, so the Bill not only tears up the Lansley reforms but quietly changes the 2003 amendments. Monitor was set up as the regulator of foundation trusts, and was to be the approver of applications to become a foundation trust.
Foundation trusts have had many incarnations, but were once heralded as the vigorous, autonomous new organisations that would shake up the NHS and bring choice and competition into healthcare. They were beyond the reach of those nasty bureaucrats who ran the rest of the NHS. However, as I think we have seen today, it has not quite turned out like that. There must be a clever saying somewhere that “All health service reforms end in failure”, just like all politicians’ careers—although the Minister is clearly an exception to that!
It is fair to say that we are seeing the end of the foundation trust experiment. There is no evidence that the new foundation trust model did any better than the old model. Of course, the first few anointed foundation trusts did outperform non-foundation trusts, but that was because they were already the best-performing trusts. That was why they were allowed to become foundation trusts in the first place. It was, really, a self-fulfilling prophecy, but, as time has moved on, it has been harder and harder for trusts to excel to the level originally envisaged.
Foundation trusts did have some good characteristics; they did have a better go at accountability to their governing bodies. Given this Bill’s focus on involving patients and the public in the wider health system, perhaps this system also has some positives—something to commend it. It might not have been a bad idea to have an equivalent model for the governance of ICBs, but I will not return to that now. I know the Minister has not warmed to our suggestions of greater accountability, but I will leave that for him to consider if he brings forward amendments on Report.
The Lansley Act favoured foundation trusts and made the optimistic—and what turned out to be highly inaccurate—assumption that, in time, all NHS providers would become foundation trusts. As so much happened with that Act, however, it turned out not to be the case at all. Foundation trusts are now no different from the old-school, old-style NHS trusts—a “distinction without a difference”, as Lord Stevens once quipped. For all relevant purposes, NHS trusts and NHS foundation trusts are performance-managed in exactly the same way.
Justin Madders
I can assure my hon. Friend that I will not waste opportunities to refer to the waste of public money as a result of the Lansley Act, but the wider point is one that the Opposition have made already in Committee and will continue to make. There is clearly a gap where accountability ought to lie. It will be interesting to hear what the Minister says about why the governing model for foundation trusts cannot be expanded to all remaining trusts. We would particularly want to see far greater patient involvement in the integrated care systems in the Bill. Clearly, we have had that debate unsuccessfully, but I hope that we will perhaps have an opportunity to return to it once the Bill returns from the other place.
I will say a few words on the licensing scheme. Given that the Bill marks an end to the whole era of markets and competition and a move, at least in theory, to a model of collaboration and co-operation—not a cartel, as my hon. Friend the Member for Bristol South might call it—why is it necessary to license NHS bodies that are now fully under the control of NHS England and the Secretary of State? That does not seem to be a particularly good use of anyone’s time, and it will create more unnecessary paperwork and bureaucracy.
We will do our best to help the Minister in reducing obstacles to delivering patient care, so we will not oppose these clauses. However, we think that they have probably not gone far enough. They are clearly a necessary tidying-up job, but the Government should do the job fully and properly.
Edward Argar
As ever, I am grateful to the shadow Minister. He should be optimistic—perhaps not on this issue, but more broadly—about the reception of some of his suggestions. I think I managed to take him aback slightly last week with one suggestion, although it was perhaps not the one with which he expected me to be willing to engage. I always listen to and consider carefully what he says.
The shadow Minister made a number of points. He mentioned the references to Monitor and TDA and said there are no references to NHS Improvement. That is because NHS Improvement is not the named body in law—that is simply a legal distinction. The named bodies are the NHS TDA and Monitor, which we understand and know as NHS Improvement.
I gently chide the shadow Minister. His reference to the chair of NHS Improvement, Baroness Harding, was a little unmerited. She has worked tirelessly. Colleagues will have their views, as is entirely appropriate in this place, but his reference was uncharacteristically uncharitable.
Karin Smyth
Given that the Minister, who I think is an honourable man, has mentioned that, does he think it acceptable for the chair of NHS Improvement to take the Conservative Whip in the House of Lords, as was outlined in the pre-screening scrutiny commission by the Health and Social Care Committee? Does he think that is acceptable, as other Ministers have not done so?
Edward Argar
I believe that all appointments, including that one, are conducted entirely appropriately, in line with Cabinet Office guidance.
I move on to the shadow Minister’s substantive points, which he perhaps made more in hope than anything else. We are not resiling from the value that choice and competition can bring, but we recognise that it is not the only driver of improvement and that collaboration plays a key role, so the position is perhaps a little more nuanced than he might like to suggest or wish to see. What we are seeing here is a reflection of the reality. We are ensuring that the way the system has evolved in practical terms over time is reflected by updating the appropriate legislation.
The shadow Minister mentioned a number of specific points around foundation trusts, and I hope I can give him some reassurance. We are not abolishing foundation trusts or their rights. The licensing system that we are talking about allows for equivalent management of both types of trust in a consistent way, and the NHS will still have the power to authorise new foundation trusts in the future, if they meet the appropriate criteria.
Justin Madders
I think the Minister probably has the gist of what I was getting at in my comments. Can he tell us how many applications for foundation trust status are currently in the pipeline?
Edward Argar
The shadow Minister is an able parliamentarian. I hesitate to say with certainty, but my belief is none at present. However, I caveat that by saying I would not wish to mislead the Committee. If I have got that wrong, I will of course let him know.
There is nothing that stops the evolution of trusts into foundation trusts, if they so wish and meet the criteria. What we are saying here is that it is not one size fits all. We will not force anyone down that route, but the option remains for NHS England. I would argue that the way the system has evolved is a reflection of the strength of that system and the framework that we have put in place around it. On a serious note, I know that the point about foundation trusts is of considerable interest to the shadow Minister. When we reach clauses 51 to 57, which cover this issue and the operation of foundation trusts, I suspect that we may get into rather more detail about how they actually operate. I might even be able to confirm that my understanding of the figure for which he asks is correct.
The shadow Minister has made his points clearly, but I hope the Opposition will agree to these clauses. They are technical clauses in essence, and the shadow Minister has rightly used them to air broader issues that are related. They are technical clauses to reflect the reality of the evolution of the system.
Question put and agreed to.
Clause 26 accordingly ordered to stand part of the Bill.
Schedule 5 agreed to.
Clauses 27 to 32 ordered to stand part of the Bill.
Clause 33
Report on assessing and meeting workforce needs
Chris Skidmore
I beg to move amendment 94, in clause 33, page 40, line 6, leave out from beginning to end of line 11 and insert—
“(1) The Secretary of State must, at least once every two years, lay a report before Parliament describing the system in place for assessing and meeting the workforce needs of the health, social care and public health services in England.
(2) This report must include—
(a) an independently verified assessment, compliant with the National Statistics Authority’s Code of Practice for Statistics, of health, social care and public health workforce numbers, current at the time of publication, and the projected workforce supply for the following five, ten and 20 years.
(b) an independently verified assessment, compliant with the National Statistics Authority’s Code of Practice for Statistics, of future health, social care and public health workforce numbers based on the projected health and care needs of the population for the following five, ten and 20 years, consistent with the Office for Budget Responsibility long-term fiscal projections.
(3) NHS England and Health Education England must assist in the preparation of a report under this section.
(4) The organisations listed in subsection (3) must consult health and care employers, providers, trade unions, Royal Colleges, universities and any other persons deemed necessary for the preparation of this report, taking full account of workforce intelligence, evidence and plans provided by local organisations and partners of integrated care boards.”
This amendment would require published assessments every two years of current and future workforce numbers required to deliver care to the population in England, based on the economic projections made by the Office for Budget Responsibility, based on projected demographic changes, the prevalence of different health conditions and likely impact of technology.
Justin Madders
I will speak to amendment 94 and the other amendments in my name and the names of my hon. Friends, since they are grouped together and we are clearly all talking about the same thing. There is probably only a cigarette paper between many elements of these amendments and, I hope, the Minister’s position when we get to the end of the debate.
One reason why there are so many amendments and they are all fairly similar is that it was clear from the evidence sessions that this is one of the few areas on which there was complete agreement among the witnesses. Clause 33 is simply nowhere near good enough. Given the importance of workforce issues, which is the most crucial issue facing our NHS and social care system—as the right hon. Member for Kingswood mentioned, social care must be included within this—it is strange that we have really quite a tepid offering in the Bill.
It feels as though the whole question of workforce is firmly in the Department’s “too difficult” box. It knows it has to do something; it knows that without the tremendous efforts of the staff the NHS would simply collapse, but rather than coming up with an effective strategy, it has produced this fig leaf of a clause to create the impression that the issue is being taken seriously and dealt with.
Justin Madders
It is now in the Minister’s inbox, and he will know that what is currently in the Bill does not cut it in terms of the challenges we face. As I often do, I place on record our thanks and admiration for the whole NHS workforce, for turning from theory into reality an organisation that demonstrates the benefits of collectivism and socialism and is one of the nation’s proudest achievements—I certainly expect the Minister to agree with the latter part of that sentiment, if not the former.
I have said this many times before, and I will say it again: without its workforce, the NHS is nothing. It is not only the doctors and nurses, but all the others who contribute to the delivery of a comprehensive and universal service, free at the point of use: the radiographers, the porters, the cleaners and the allied health professionals. I will not list them all, but we should acknowledge that a number of different people contribute towards even the most straightforward engagement with a patient, and we are grateful for each and every one of them and the service they give.
I briefly refer hon. Members to the report by the Health and Social Care Committee on workforce burnout and resilience. It conducted an inquiry into the issue and found that staff shortages were
“ultimately the biggest driver of burnout.”
It was presented with much evidence from staff about feelings of low energy or exhaustion, increased mental distance from or negative feelings about the job, and reduced professional effectiveness. Excessive workload was identified as the key predictor of staff stress, workers’ intention to quit and patient dissatisfaction, and was also highly associated with the level of errors.
I draw this Committee’s attention to some of the conclusions in the report. Paragraph 22 states:
“It is clear from our witnesses that although the People Plan presents comprehensive ambition to address the failings in the culture of the NHS, and address the needs and wellbeing of NHS staff, its delivery will depend on the level of resourcing allocated to these priorities. Without adequate funding the laudable aspirations of the People Plan will not become reality.”
Paragraph 23 states:
“We recommend that the Department publishes regular, costed updates along with delivery timelines for all of the proposals in the People Plan.”
That is something we are trying to turn into reality with our amendments.
Turning to the specifics of amendment 40, paragraph 24 of the Select Committee report states:
“The absence of a People Plan for social care serves only to widen the disparity in recognition and support for the social care components of health and social care. The Government should rectify this as a matter of urgency in their upcoming work to reform the social care sector; and it is essential that it is included in the social care reforms promised this year.”
Some reforms have been promised, but we still await the further White Paper on integration, which we have touched on many times.
“The adult social care workforce has stepped up to the plate during the pandemic. They deserve the same care and attention that the People Plan pledges to NHS colleagues.”
We wholeheartedly agree with the sentiments stated there.
Edward Argar
I am grateful to all the hon. Members for tabling the amendments. They relate to increasing the Government’s accountability for assessing workforce planning and setting workforce projections. Before I turn to their substance, as the hon. Member for Ellesmere Port and Neston suspected, I entirely agree with the latter half of his sentiment about the achievement that is the NHS. I am not sure I would necessarily attribute that to unbridled socialism, which tends to fail where it is tried. However, as Opposition Members will know and as set out well in the book written about Nye Bevan by their right hon. Friend the Member for Torfaen (Nick Thomas-Symonds), which I re-read over the weekend, the genesis of the NHS was a complex one, which owed much to all parties in the House.
Justin Madders
I am glad the Minister has time to be reading such excellent tomes over the weekend. Can he remind us what the Conservative party did when voting on the original National Health Service Act 1946?
Edward Argar
Could the hon. Gentleman remind me what the Labour party did when in government, resulting in the resignation of the architect of the NHS?
The point I make is a serious one. The genesis of the NHS which, quite rightly, we are all proud of and recognise as a great achievement, is far from as simple as sometimes it might be portrayed by both parties in the House. The hon. Gentleman is right to highlight the fact that while the new hospitals we are building, the developments in drugs and therapeutics, and the new technology and new kit are all hugely important, they are limbs of the NHS. Its beating heart is its workforce and he is right to highlight that. I join with him, as I often do on these occasions, in paying tribute to all those who make up that beating heart.
Continuing to grow the workforce remains a top priority for the Government. Although I may disappoint some hon. Members, I am genuinely grateful to those who tabled amendments and spoke to them today, because this is a crucial debate, and I suspect the matter will continue to be raised, not just during the passage of the Bill but, rightly, more broadly. As ever, I am grateful to my right hon. Friend the Member for Kingswood, who brings a high degree of expertise to this subject, as the only hon. Member or right hon. Member to have occupied both the office that I now occupy and that of Minister of State for Universities, Science, Research and Innovation. He brings to the Bill the perspective he has gained from both those offices.
When I got this job back in September 2019, which seems like an age ago, I was responsible for workforce for a few months, until that responsibility was taken on by my hon. Friend the Member for Faversham and Mid Kent (Helen Whately) at the beginning of 2020. One of my first visits was to the University of Lincoln, which had just opened its medical school. That medical school had been campaigned for very hard by my hon. Friend the Member for Lincoln (Karl MᶜCartney), who was out of office at the time, and by the then Opposition Member for Lincoln.
The hon. Member for Bristol South is absolutely right to highlight the importance of local medical schools. Lincolnshire, for example, has a challenge in attracting and retaining a workforce. We are already in the early stages of seeing a growing workforce of people there who are likely to start their careers in Lincoln. When I visited, my right hon. Friend the Member for Kingswood was remembered with fondness. I did not take it personally that they almost seemed disappointed to see me and not him, but that is a reflection of the affection in which he is held and the respect for him in this sector.
As the shadow Minister rightly said, yesterday I again resumed responsibility for the NHS workforce and I look forward to working with him constructively on these matters, which is the way we tend to work. We will consider the role that all stakeholders can play in identifying the needs and opportunities around the workforce. I always value input and I echo the words of my right hon. Friend, which I hope will find favour with the shadow Minister, that that includes input from professional bodies, think-tanks, NHS bodies and the trade unions. There may be times when we disagree, but I look forward to working with all of them constructively and courteously, as I do with the shadow Minister.
This year, we have seen record numbers of nurses and doctors working in the NHS, and the total number of NHS staff has increased to almost 1.2 million. There are over 17,800—2.9%—more professionally qualified clinical staff working in NHS trusts and clinical commissioning groups than in June 2020, including over 2,700, or 2.3%, more doctors and over 8,900 more nurses.
We continue to make good progress towards meeting our manifesto commitment of 50,000 more nurses by March 2024. Encouragingly for future workforce supply, applications for nursing and midwifery courses in England were up 21% this year compared with last year, and we have seen the highest number of students accepting places in the past 10 years. Through Health Education England, we will continue to invest in the NHS and social care workforces, and an additional duty is not required for this to happen.
I will not repeat the point that the shadow Minister very kindly made about the July commission. I will certainly look into the status of the response to that report. He will recognise that even when we do not agree, which is not that often, although there are such times, I endeavour to be efficient and courteous in responding to such matters, so I look forward to picking up on that with my new responsibilities.
Justin Madders
I certainly did not intend to upbraid him for not responding, given that he took over responsibility only yesterday. He will be aware of the importance of the report and of an official response.
Edward Argar
I am, of course, and I reassure the hon. Gentleman that prior to the reshuffle I was looking at a number of issues related to the recovery of our workforce. A fit, healthy and supportive workforce is crucial to that. I have read and considered the report, and, with my new responsibility, I will endeavour as swiftly as I can to ensure that the Government respond as appropriate to the Committee, and to Committee reports more broadly, in a timely fashion.
We believe that the proposed duty in clause 33, which inserts proposed new section 1GA into the National Health Service Act 2006 in order to require the Secretary of State to produce a workforce accountability report at least every five years, addresses one of the main issues in the current system: the need for greater transparency and accountability for the various bodies involved in the workforce planning process in England. The proposal in the Bill is to ensure that there are proper structures and accountability for ensuring that the necessary workplace planning and projections are carried out and co-ordinated effectively by the various bodies in the system. For example, the report will set out the role and responsibilities of the new ICBs and how they will support the delivery of effective local and national workplace planning.
Draft guidance issued by NHS England, which covers the role of ICBs regarding the workforce, sets out the direction of travel in that regard. It sets out the ICBs’ responsibility to develop system-wide plans to address current and future workforce supply for the local area, with demand and supply planning based on population health needs. The guidance also refers to their responsibility to provide workforce data to regional and national workforce teams in order to support aggregated workforce planning and to inform prioritisation of workforce initiatives and investment decisions.
I fear that my remarks may be a little more lengthy than usual, but I think that that reflects the importance and breadth of this issue. Turning to the other amendments in the group, amendment 2 would require the Secretary of State to publish the report on assessing and meeting the workforce need annually, rather than at a minimum of every five years. I acknowledge the witnesses’ comments, which the shadow Minister has rightly highlighted, but we need to be a little cautious. We cannot predict all future evolution and needs, which is why we have mandated the report to be published at a minimum of every five years. That flexibility allows us to provide an updated report in order to reflect any changes to roles and responsibilities earlier than the statutory required period, if necessary, but requiring an annual report would impose an unnecessarily prescriptive and, I fear, rigid arrangement on the production of this document and would be disproportionate to the level of change in roles and responsibilities that we expect to see in the system on an annual basis. I therefore suspect that it is a matter for debate as to what the most appropriate timescale is—we have therefore set a minimum period, rather than a maximum period.
Amendment 40 seeks to go further than our current duty on reporting workforce accountabilities, by requiring the report to set out the system in place for assessing and meeting workforce needs, both of the health service and of social care. As the shadow Minister has alluded to, and as he and I agree, our 1.5 million-strong social care workforce is an absolutely essential and valued part of the social care system and, indeed, our broader healthcare system in this country. Social care workers are on the frontline, caring for and supporting people at the heart of their communities.
I understand the intention behind the amendment, but I fear that we will not be able to accept it today. The scope of clause 33 as it stands has been carefully drafted to ensure that it reflects the statutory role and responsibility of HEE, which will assist in the production of the report. As a result, the workforce accountabilities report will cover the NHS in England, including primary, secondary and community care; the regulated adult social care workforce where sections of the workforce are shared between health and social care—for example, registered nurses and occupational therapists; and the regulated public health workforce, including doctors and other regulated healthcare professions. Regulated professionals in adult social care are therefore already included in the scope of the report, but HEE has no specific remit for the wider, unregulated adult social care workforce. I can reassure the Committee, however, that the Government are working hard to bring forward a White Paper for adult social care. As the shadow Minister rightly alluded to—he repeated his comments, so I will repeat mine—the proposal set out by the Prime Minister will build on the strong foundations for reform and integration that will be laid through the Bill.
Justin Madders
I will not tempt the Minister to tell us what will be in that, but his confidence that it will be an improvement on the current position is noted. Does he anticipate that the White Paper will also include a very clear commitment to a workforce strategy, along the lines that we have discussed?
Edward Argar
I do not know whether the shadow Minister has seen what I was about to say, but after two years of doing this together, he has become relatively psychic. I anticipate that the White Paper will set out in detail how we propose to fund social care professionalisation, as well as initiatives or plans to improve workforce wellbeing and further reforms to improve social care recruitment and support.
Sarah Owen (Luton North) (Lab)
I know it is not the done thing for Whips to contribute to debates, but because I have been a care worker, this part of the Bill is close to home for me. I wanted to touch on the word that the Minister used when he spoke about “assumptions” about workforce planning. Does he agree that actual independence takes away the need for Ministers to make assumptions, and that is why the amendment is important? Otherwise, Ministers are in danger of marking their own homework when it comes to whether they have met the workforce projections that they say they have met.
Edward Argar
The hon. Lady alludes to it not being normal form for a Whip to intervene, but her contribution is, as ever, extremely valuable in this context—particularly given the work that she did before she became a Member of this House—and I am grateful to her. My counterpoint would be that we need to be cautious about a separation of projections and planning from the reality of day-to-day delivery. The system, as envisaged, will bring together an actual knowledge of what is going on on the ground with those projections and data delivery.
I suspect that I will not convince the hon. Lady, but I recognise and acknowledge the expertise that she brings to the area. Back in my days as a councillor, I was a cabinet member for adult social care and saw at first hand the amazing work done by care professionals and by volunteers in the care sector. Notwithstanding any political disagreements we might have, I pay tribute to her for that.
Finally, regarding the consultation requirements in amendments 94 and 41, I assure the Committee that consultation already happens throughout the workforce planning and delivery process. To give a recent example of such engagement, HEE completed a call for evidence as part of its refreshed “Framework 15”. That call for evidence closed on 6 September and received responses from a wide variety of bodies. Between October and April of next year, engagement and consultation will continue through various events led by HEE. I am sure that as I assume my new responsibilities, I will occasionally be questioned on those by the shadow Minister, either across the Dispatch Box or in written questions and letters, as is his wont and, indeed, his right.
At local level, ICBs will be under various workforce-related responsibilities and obligations, as I have set out. As part of that work, we can expect ICBs to work with local stakeholders in their area. We expect all this stakeholder consultation to continue, but we want engagement to be flexible, in keeping with one of the principles—the permissive principle—behind the Bill.
Let me turn to the issue of safe staffing. Amendment 42 would significantly amend our proposed workforce accountability report so that it would have to cover an assessment by the Secretary of State of safe staffing levels for the health service in England and whether those were being met. The effect of the amendment in reality would be to require the Secretary of State to make such an assessment but, in so doing, risk detracting from the responsibility of clinical and other leaders at local level for ensuring safe staffing, reflecting their expertise and local knowledge, supported by guidance and regulated by the Care Quality Commission. We do not support the amendment as drafted, for various reasons.
First, there is no single ratio or formula that can calculate the answer to what represents safe staffing in a particular context, and therefore against which the Secretary of State could make an objective assessment. It will, as we have seen over the past year and a half, differ across and within an organisation. Reaching the right mix, for the right circumstances and the right clinical outcomes, requires the use of evidence-based tools, the exercise of professional judgment and a multi-professional approach. Consequently, in England, we think that the responsibility for staffing levels should remain with clinical and other leaders at local level, responding to local needs, utilising their expertise, supported by guidelines from national bodies and professional organisations, and all overseen and regulated by the CQC.
Secondly, the amendment would require the formulation of safe staffing levels against which the NHS workforce could be assessed. I fear that that would be a retrograde step, as it would inhibit the development of the more productive skill mixes that are needed for a more innovative and flexible workforce for the future. That new workforce is crucial to successful implementation of the new models of integrated care that the Bill is intended to support.
The specific wording of the amendment is incredibly broad and would require the Secretary of State to assess safe staffing levels across all healthcare settings, across the whole of England, for all medical and clinical staff. Such a duty would be burdensome not only for the national system but, potentially, locally—for local clinical leaders. It would move us away from that local accountability and expertise.
I assure the Committee that we will continue to engage with stakeholders and hon. Members, including my right hon. Friend the Member for Kingswood, to look closely at this area. I want to reassure Members, including Opposition Members, that we have heard their concerns and the views that they have expressed in relation to workforce in today’s debate and reflecting the evidence of witnesses. I am grateful, as ever, for the tone in which the shadow Minister has raised his concerns and put his points. We will carefully consider these issues and continue to ensure, and to reflect on ensuring, that we work to address them through the Department’s wider work on workforce.
Let me just say, before concluding, that while we were doing the changeover between clauses, I did a very quick check and I believe I was correct in my answer to the shadow Minister that no applications were currently pending for foundation trusts. I wanted to clarify that it turns out I was right—I suspect he thinks he was right in his assumption as well.
For the reasons that I have set out, I encourage hon. Members not to push these amendments to a Division but to continue engaging with me and other Ministers.
Chris Skidmore
I thank the Minister not only for his kind words to me personally, but for his considered response to this set of amendments. It is clear that he is mulling over this, and I would like to give him time to think about potential opportunities for changing the clause. I know how these things work; I have sat in the very same seat that he is sitting in. I know he has to spin off various pieces of paper that have been provided to him by departmental officials. The officials who are sitting here have listened to this debate and will want to go back to the Department to discuss with their colleagues what has been mentioned in Committee today.
There is a gap between the sector’s expectations of what workforce planning might look like and what is currently written in the Bill. The Minister has proven my amendment to be defective. It is already highlighted in the legislative remits of Health Education England that it has to consult the social care sector and also the wider sector. I will not press the amendment to a vote, but I do think there is an opportunity. If we can plan in advance and create systemic frameworks, we will save ourselves time—a stitch in time saves nine. We have an opportunity to provide certainty and security for the workforce and to provide a sustainable framework, although I am not sure whether the five years is sustainable.
As I have mentioned before, I was here 10 years ago on the Committee for the Health and Social Care Bill, which became the Health and Social Care Act 2012. We are now removing parts of that, and the Minister at the time, in the very same seat, argued until he was blue in the face that there would be a benefit. We can learn from that experience, but the lived experience of professionals suggests we need to be more frequent in our assessment of the workforce needs of the NHS and the care sector.
We know that the demographic train that is coming down the tracks is going to hit us. We have seen what has happened with gas supply prices and the energy sector; we knew nine years ago that we had only about four days’ gas supply, and yet no action was taken. If we transpose that over here, we know that we face workforce issues, if not a crisis, in the next 10 years. That will all come down the tracks in a perfect storm of increasing healthcare issues, an ageing population and an attrition rate in a workforce that cannot currently keep up with demand.
There are supply and demand issues. We need more frequent assessments to ensure that supply and demand meet each other, and we need investment in the workforce and in training. Although I will withdraw amendment 94, I am keen for the Minister to consider what further action might be taken on Report or in the other place. I beg to ask leave to withdraw the amendment.
Hywel Williams (Arfon) (PC)
I beg to move amendment 85, in clause 33, page 40, line 11, at end insert—
‘(3) The Secretary of State must consult the Welsh Ministers before the functions in this section are exercised.”
This amendment would require the Secretary of State for Health and Social Care to consult the Welsh Government before the functions on workforce assessments in this clause are exercised.
I will be brief, given that much of what I would otherwise have said has been covered in the debate on the previous group of amendments. I will just say to those on the Front Benches, in their discussion of the genesis of the NHS, that success has many parents. Aneurin Bevan of Tredegar was the father of the NHS, based on his experience of the provision of health in that area, but it was also based on the foundation that was set up by my predecessor but three as Member for Caernarfon, David Lloyd George.
Having got that out of way, the amendment would place a duty to consult the Welsh Government on workforce assessments. Although the amendment is a probing one, I am concerned that the devolution settlement remains somewhat complicated and sometimes unclear, even in its current iteration. As a piece of history and a reference to how that settlement can cloud matters, I will mention a question I asked a former Labour Secretary of State for Health, Mr Alan Milburn, some years ago about nurses’ pay. His response, which I committed to my memory, was “It is one of the abiding joys of my life that I have no responsibility for things Welsh.” Unfortunately for both Wales and him, he actually had responsibility for nurses’ pay at that time. Even Secretaries of State are not perfect, let alone Ministers of State and others. That situation has now been resolved.
The danger is always that the remaining integration of parts of the Welsh health service and health service in England might be overlooked. I referred to that earlier in respect of services and people from Wales—and people from England, for that matter—accessing health services on the other side of the border. People in north Wales specifically will recognise the names of individual hospitals in England. I refer briefly to Alder Hey on the Wirral, which provides services to children with severe conditions. There is the Royal Liverpool; the Christie in Manchester, which provides specialist cancer treatment; and the hospital in Gobowen, which has for a long time provided orthopaedic services. Recently, severe casualties and people who have suffered road traffic accidents have been helicoptered to Stoke for specialist treatment. As I said the other day, around 13,500 Welsh people access GP services in England, and 21,000 or so people from England access GP services in Wales. Those are the 2019 figures.
The workforce-training and education aspects of cross-border arrangements must be considered because staff are mobile. People from Wales access training in England and then return to Wales, and it works the other way around as well. In my own constituency specifically, the school of nursing at Bangor University has for a number of years trained nurses from all over the UK and elsewhere. We are now establishing a medical school that will certainly be training doctors who will return to Scotland, England or Northern Ireland.
The other positive opportunity that proper workforce planning would present the health service throughout the UK is in the specialisms that we hope to develop in Wales—particularly in my area of north Wales. Those specialisms include, for example, treating injuries arising from accidents on our coasts and mountains, for which we already have some specialism. There are also particular issues around mental health and multilingualism, particularly in talking therapies and work with children and older people.
There are opportunities for people who might be trained in Wales before going over to England, and vice versa. For the reasons that I have outlined, I think it essential that those matters be taken into consideration in workforce planning.
Alex Norris
It is a pleasure to serve with you in the Chair once again, Mrs Murray, and to follow the thoughtful contribution by the hon. Member for Arfon.
The hon. Gentleman’s points about interdependency are important. Of course, we cherish and build on the devolved settlement, but we understand that we still have important relationships, not least at our borders. I thought that his point about specialised care was a thoughtful one, too: we know that as conditions or treatments become complex, there will be specialisations, and we would never want artificial barriers to get in the way of people accessing specialised care. His point about training was also good and jumped out to me.
Yesterday, I spoke to a surgeon in my community who took great pride in working in the hospital where he was born. In between, he had gone away; I am told that there are parts of the world other than Nottingham—I dispute that fact—and he wanted to go and see some of them. That will inevitably involve crossing borders, and it is important that that is reflected in the Bill. That will happen from nation to nation, but in the future it will happen from integrated care system to integrated care system. Where there is divergence, we need to be thoughtful of it.
The statement of values relating to cross-border care said:
“no treatment will be refused or delayed due to uncertainty or ambiguity as to which body is responsible for funding an individual’s healthcare provision.”
That is an important principle because it sets out that it is the job of the system rather than the individual to understand and navigate the separation between different bodies that may diverge but which work together in common purpose. That is easy to say, but hard to do at times. As I say, that is something that we will see between integrated care systems in time, too. That is true for patients, but also for staff, whether those staff work in Wales but live in England or vice versa, and for the important interrelationships between border integrated care systems on the Welsh border and the NHS in Wales.
There will be devolved and separate competencies between those bodies, but the human beings who make those systems go live side by side in communities, sometimes even next door to each other. A decision taken in one place, of course, impacts on everybody; we see that a lot in social care. Local authorities are under so much pressure at the moment, both in the resources that they have to fund social care and finding individuals to staff that care. There could be price wars at the borders that mean that individuals move between organisations more frequently than they would in a system that was better planned. We have to be mindful of that.
During the evidence sessions, we heard about the safe staffing legislation for nurses in Wales. That is the sort of thing that would already impact on border CCGs, and will do on integrated care systems in due course. That will only grow as the considerable workforce pressures that we discussed in the previous debate bite down even harder. Again, we must be mindful of that. It is crucial that there is a collective approach—a minimum approach—where the NHSs in neighbouring nations have due regard to each other. If the workforce becomes a zero-sum game, we will all lose in the long term.
I was heartened in those proceedings to hear about the contact between the Minister and his colleagues in Wales. I know that he takes matters seriously in Wales and across the United Kingdom, which is good. We might hear more about how that works with regard to the work- force. In the meantime, we support the inclusion of this measure in the Bill and the fact that it will be a priority.
Edward Argar
I am grateful to the hon. Member for Arfon. Although I represent an east midlands constituency, in sunny Leicestershire—the hon. Member for Nottingham North would argue that Nottinghamshire is sunnier—I have a huge affection for Wales. In every speech he gives, the hon. Member for Arfon brings to the fore his pride in Wales and his constituency. In the vein of highlighting successful politicians representing Welsh constituencies, I take this opportunity to put on the record a tribute to my former Parliamentary Private Secretary, my hon. Friend the Member for Ynys Môn, who has become the PPS to the Secretary of State for Wales. I congratulate her on that appointment. It is well deserved; she has looked after me very well during her time in this House. I am grateful to her and put my congratulations to her on the record.
I am grateful to the hon. Gentleman for bringing the amendment before the Committee. It would require the Secretary of State to consult Welsh Ministers before the functions contained in clause 33 were exercised. Clause 33 would insert proposed new section 1GA into the National Health Service Act 2006, which, as we have just debated, would require the Secretary of State to publish, at least once every five years, a report describing the system in place for assessing and meeting workforce needs of the health service in England.
The shadow Minister, the hon. Member for Nottingham North, alluded to a point regularly made to me by my hon. Friend the Member for Vale of Clwyd. Although politicians and people in this House might see neat administrative boundaries drawn on a map, the reality is often much more complex. Certainly, those boundaries should not be seen in their everyday lives by constituents and others, who on occasions rightly need to exercise their right to access specialist services in England; I dare say there will be occasions where the counterpoint is true, and people living on the English side of the border may access health services on the Welsh side. We need to recognise that and work pragmatically with that reality.
Although in many other areas of the Bill we will work closely alongside the devolved Administrations, we do not agree that there is a formal need to impose an obligation in the legislation to consult Welsh Ministers before the Secretary of State exercises the specific power in proposed new section 1GA. I will turn to how we work with the Welsh Government in a moment.
Hywel Williams
I am not entirely reassured by the Minister’s words; possibly the best response is, “We shall see”.
I make one further point, if I may, in reference to his former Parliamentary Private Secretary: people from Ynys Môn are known in Welsh as people from “Gwlad y Medra”, which translates as “the land of I can do it”. Clearly, she can do health, and we look forward to seeing her performance at the Wales Office as well. I add my congratulations to her. I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Question proposed, That the clause stand part of the Bill.
Edward Argar
Can I clarify, Mrs Murray, that we have a hard finish at 11.25 am?
Edward Argar
I will endeavour not to be on my feet at that moment.
Clause 33 inserts new section 1GA into the National Health Service Act 2006, which sets out a duty on the Secretary of State to report on workforce systems. Under the duty, the Secretary of State is required to publish, at least once every five years, a report describing the system in place for assessing and meeting the workforce needs of the health service in England. A duty is also placed on HEE and NHS England to assist in the preparation of the report, if asked by the Secretary of State to do so.
As we have discussed this morning, the report will describe the workforce planning and supply system for healthcare workers, including those working in the NHS and public health, alongside regulated healthcare professionals working in social care and other sectors in England. The report will be published at a minimum—I emphasise in each of my remarks that word “minimum”, although the shadow Minister may feel that it is not sufficient—of every five years. However, I can commit to that publication cycle being kept under review by the Secretary of State, should circumstances change.
Clause 33 will provide greater clarity and transparency on how the workforce planning and supply system operates in England. The report produced under it will describe in one single document the workforce planning and supply roles and responsibilities of relevant national bodies, including the Department, HEE and NHS England, the new integrated care boards and individual employers, and how they work together in practice at national, regional and local levels.
Clause 33 will complement our ongoing non-legislative steps and investment in workforce planning in England. In July 2021, the Department commissioned HEE to work with partners to review longer-term strategic trends for the health and social care workforce. This important programme will review, renew and update the existing long-term strategic framework for the health workforce—HEE’s framework 15—and will genuinely help to ensure that we have the right numbers, skills, values and behaviours to deliver world-leading clinical services and continued high standards of care.
Alongside the work that we are already doing with NHS England and HEE, clause 33 will further improve accountability for all the bodies involved on the important subject of planning for and meeting future workforce supply and demand.
Justin Madders
I will not detain the Committee for long; I have said more than enough on the subject—not persuasively, clearly.
The Minister made the point that I did not think that a minimum of five years was sufficient for a report on the workforce, and that is absolutely correct—and I am not alone, by any stretch of the imagination. Every stakeholder and every person who gave evidence to the Committee said that five years was simply insufficient to deal with the magnitude of the challenge that we face. If the Department really wants to grasp the nettle, it should be taking heed of what those stakeholders said.
The workforce is a very complicated and ever-changing issue. It is part of a world market in healthcare staff. What the right hon. Member for Kingswood said about his amendment was important: simply to dip into other parts of the world when we are running short is not a solution. Not only is it morally difficult to justify, but it does not represent a long-term solution—we are as prone to losing staff to other parts of the world as anyone else. People will remember that the junior doctors’ dispute resulted in an exodus to Australia and other parts of the world. Going around the world and dipping into other countries’ healthcare resources is not a solution to the challenges that we face. We are not going to divide the Committee on clause 33, but we think that it is insufficient.
I repeat the Health and Social Care Committee’s finding that
“workforce planning was at best opaque and at worst was responsible for unacceptable pressure on staff.”
That really cannot be ignored. We cannot keep kicking the can down the road. I hope that when the clause gets to the other place, there is more success in putting the onus on the Government to deal with the challenge.
Edward Argar
I hear what the shadow Minister says, and I hope that I can give him some reassurance: the Government will continue to reflect very carefully on the points made both in the debate today and in our evidence session.
Question put and agreed to.
Clause 33 accordingly ordered to stand part of the Bill.
Ordered, That further consideration be now adjourned. —(Steve Double.)