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Baroness Tyler of Enfield
To ask Her Majesty’s Government what assessment they have made of the report by the Royal College of Nursing Nursing Under Unsustainable Pressures: Staffing for Safe and Effective Care in the UK, published on 6 June.
Baroness Tyler of Enfield (LD)
My Lords, I am very pleased to open this important debate on the pressures facing the nursing workforce, who play a critical role in our overall healthcare system. Throughout the Covid pandemic, nurses constantly went the extra mile, and more, often at great personal cost. Indeed, I want to pay tribute to all health and social care workers who toiled through the pandemic with great self-sacrifice. We should never forget their heroic and unstinting labours. I refer to my declared interests in the register, particularly as a non-executive board member of the Royal Free London NHS Foundation Trust.
Last week, the Royal College of Nursing published Nursing Under Unsustainable Pressures: Staffing for Safe and Effective Care in the UK. It reported on the results of the RCN’s March survey, which asked staff about their last shift—that is, the last time that they were at work—and compared the results with earlier surveys from 2017 and 2020. It makes for salutary reading. The report states that recent events, including the UK’s exit from the EU and the pandemic, have highlighted and worsened long-term problems with workforce supply in health and social care. The findings highlight starkly the impact of growing staff shortages and rising demand on the ability to deliver safe and effective care.
To give a brief flavour of the report’s findings, only 25% of respondents said that their last shift had had the full number of planned registered nurses; 75% of respondents reported a shortfall of at least one registered nurse on their shift; and four in five respondents felt that patient care was compromised by not having enough registered nurses on the shift—these figures had all gone up since the previous survey. Also, only around one in five respondents agreed that they had enough time to provide the level of care which they would like.
There is a lot more besides, but these findings give us cause for real concern, in terms of morale and staff retention and in the impact on patients and their safety. Frequently, nurses felt that the quality of care that they were providing was compromised, ranging from basic personal care, such as helping patients going to the toilet, through to severely ill patients getting treatment late and, sometimes, medicines not being given at all.
It is also worth looking at the key figures from the Nursing and Midwifery Council’s annual registration report. It is clearly good news that the number of nurses, midwives and nursing associates on the register has grown to more than 758,000 given the pressures of the last two years. Almost half of newly hired nurses were recruited from abroad. Of course, international nurses and other professionals make a welcome and vital contribution to the NHS, but it raises ethical and sustainability issues when so many are coming from poorer countries that often are experiencing staff shortages in their own healthcare systems. Alarmingly, however, over 27,000 nurses left the register, a sharp rise on the previous year.
When asked in the NMC’s leavers’ survey why they left, many said that their main reasons included too much pressure and poor workplace culture. More than a third of respondents said that Covid and feelings of burnout influenced their decision to leave. Some said that they were worried about their own health, while others struggled with increased workloads and a lack of staff, reinforcing the findings by the Royal College of Nursing.
What needs to happen? As the Minister will no doubt remind us, the Conservative Party pledged in its 2019 manifesto to deliver 50,000 more nurses, and progress is being made against that target, which I welcome. However, as the Chief Nursing Officer for England, Ruth May, said recently, while the pledge was welcome, it falls short of what is needed. Analysis from the King’s Fund also supports the view that the target will simply not be enough, saying that at a national level
“recruitment is having no clear impact on actual vacancy numbers or on the shortfall of nurses in the NHS”.
It went on to explain that the underlying cause of nursing shortages was that demand for nurses was increasing more quickly than supply, for reasons that it described as “complex, longstanding and varied”. However, it cited the pandemic and new targets to increase diagnostic and elective activity, which have created new demands and exacerbated workforce shortages that long pre-date Covid-19. The King’s Fund recommended a regular assessment of demand for and supply of nurses in the NHS over the next five to 10 years as the only way of tackling the backlog of care and dealing with these shortages and with rising patient demand, now and into the future.
Workforce planning is clearly crucial, and we need to see an emphasis on university nurse training programmes and the very welcome degree apprenticeship scheme, but so is a strong focus on retention, with so many nurses experiencing burnout and significant numbers intending to leave. Unfilled vacancies increase the workload pressure on staff, and it quickly becomes a vicious cycle leading to high levels of stress, absenteeism and turnover. As we know, reliance on bank and agency staff as short-term stopgaps has huge and unsustainable costs.
What is needed for nurses to make them want to stay? Clearly, pay is critical, but my view is that the NHS must focus on becoming a more attractive employer. This means tackling head on concerns expressed about bullying and discrimination, offering more opportunities for flexible working, and strengthening more people-focused and inclusive leadership. It must also include more black and minority-ethnic nurses in senior positions. In short, it requires a fundamental change in the culture to create an environment in which staff want to work and make their careers.
In talking to front-line nurses during the pandemic and more recently, I have been struck by a simple message of “We just need to get the basics in place”. While well-being support and initiatives are welcomed, the nurses I spoke to said they just wanted to know that there would be somewhere they could sit and recover at the end of a long shift, that hot food and drinks would be available during the night when many catering services are closed, that there would be someone to speak to in a non-judgmental way after dealing with difficult cases, that leave could be taken, that there would be flexibility around rotas to help with family responsibilities and support with childcare, and that they would not have to pay an extortionate amount for car parking. I think we all agree with that.
Are these things too much to ask for the nurses who look after us and our families when we are most vulnerable? In short, it means working with nurses on what really matters to them. The nurses I spoke to said that nursing can be a great job and a highly rewarding profession, but we must get the basics right so that they feel they are valued and properly supported.
Finally, I want to turn briefly to wider workforce planning issues. Like many other noble Lords, I was bitterly disappointed when calls, supported by many inside and outside Parliament, for independent, long-term workforce projection data to be routinely published went unheeded in our lengthy debates on the Health and Care Bill earlier in the year. Like many others, I believe this modelling is key to putting the workforce back on a sustainable footing, ensuring safe staffing levels and supporting more strategic spending decisions. Given this glaring gap in the Health and Care Act, it is ever more critical that workforce planning is properly addressed in the forthcoming long-term NHS strategy.
The Secretary of State for Health recently told the Health and Social Care Select Committee that while the strategy is expected to include data on workforce requirements by speciality and to provide a gap analysis to inform training plans, he could guarantee only that the conclusions would be published. He said the plan may not be published in full, including the workforce projection data. He also told the committee that the number of people waiting for NHS care stands at 6.7 million. Surely we need to know whether the NHS will have sufficient staff to meet growing demand and how many more professional staff will be trained, along- side plans to create new roles and use technology to work in different ways. Is the Minister able to explain why it may not be possible to publish the workforce plans in full, and can he confirm the dates for the publication of Health Education England’s updated Framework 15 document, looking at long-term strategic trends and drivers in healthcare, the update to the 2019 NHS Long Term Plan and the 15-year workforce strategy setting out the number of staff the NHS will need?
As we all know, the NHS faces many acute pressures and challenges such as GP recruitment, which is well off track against the target, ambulance waiting times—we heard the appalling case in the news this morning of a 94 year-old gentleman who waited five hours after a bad fall and it tragically proved fatal—building new hospitals, unacceptable A&E and cancer treatment waiting times, delays in discharging patients due to lack of social care, and the list goes on. Having the right highly skilled, dedicated and motivated workforce, both clinical and managerial, lies at the root of them all. I very much look forward to hearing contributions to this debate from other noble Lords and the Minister’s response.
Lord Lilley (Con)
My Lords, I congratulate the noble Baroness, Lady Tyler, on this debate and agree with a great deal of what she had to say by way of introduction. This report gives serious grounds for concern. Clearly, Covid has played a major part in the pressures that nurses feel, and they deserve our sympathy as well as our gratitude. I agree with many of the suggestions of a comparatively straightforward nature that she made, which might be able to alleviate some of these strains.
I will focus on an issue that the noble Baroness, Lady Tyler, raised: recruitment. She mentioned that we recruit more than half our additional nurses from abroad, and that the Royal College of Nursing said there was a problem as a result of Brexit. I looked at the Royal College of Nursing labour force survey, which shows that there is the same number of nurses from the EEA now as 10 years ago, so that has not been a problem—but we have recruited many more from other countries.
What I find particularly alarming is the recent news that more than 4,000 of those nurses we have recruited from other countries come from poor countries that themselves have a great shortage of nurses. That strikes me as immoral and wrong. I am not alone in saying that; people on both sides of the House have said it.
What puzzles me is why we do not go on to ask, “What is the alternative?” Surely the alternative is to train more of our own nurses. No one ever focuses on the fact that in the last year for which I could find figures in the Royal College of Nursing labour survey, we turned away 26,000 British applicants from nursing courses—a far higher proportion than are turned away from almost any other area of training or qualifications.
It used to be because we rationed the number of places by bursaries, which came from the NHS budget. I remember discussing with Jeremy Hunt why we had not increased that. He said he had reached the conclusion that his predecessors thought, “If I spend more money on bursaries and train more nurses, those nurses won’t be available until four or five years from now when I won’t be Health Secretary”. Of course, that was not the case with Jeremy Hunt and he was instrumental, along with George Osborne, in changing the rules so that thereafter nurses were trained out of student loans.
We thought that would end rationing, but it has not. I understand from those I speak to in the health service that there is de facto rationing because of the supernumerary rules and so on mentioned in the report. Training nurses is an encumbrance as far as the hospitals are concerned—they do not count as part of the workforce but subtract from it. I do not understand that. What I really do not understand is that those who clearly know far more about the NHS than I do never focus on it. They never use their great expertise and information to identify what is going wrong. Why are we rationing places in our universities and turning away people who want to be nurses and who we need as nurses, blighting their prospective careers and making them do something else instead? It is a scandal.
Of course, we know why. People say, “If you’re advocating British people being trained as nurses, that must mean you’re against immigration.” I am in favour of having the most highly qualified labour force we can and giving the maximum opportunities to people in this country who want to be nurses and do other worthwhile professions, rather than saying that we ought simply to make ourselves open to every form of immigration from the world.
I noticed one puzzling thing about this report. It contains a whole series of harrowing comments from nurses, and more than half of them come from nurses in Scotland. I could not see why. I claim Scottish ancestry and was brought up to believe that this made me racially superior, until I learnt that that was racism; now I just claim to be equal to everybody else. I have a natural love of Scotland, and I cannot believe that Scottish nurses are in any way different. I looked at all the answers, when they are broken down by whether they are in Scotland, England, Wales or Northern Ireland, and in almost every case the situation is more negative in Scotland, despite the fact that Scotland gets 25% more per head to spend on health than the rest of the United Kingdom. That makes me think that this is not simply a question of money; it is a question of morale, leadership and the whole ethos of the NHS.
Both in Scotland and in the rest of the United Kingdom, we ought to look at the sort of measures that the noble Baroness, Lady Tyler, has put forward to improve the lot and the work satisfaction of nurses, and at the same time see what we can do to recruit more British people into our universities to become nurses and stop us stealing nurses from poor countries that need those nurses much more than we do.
The Lord Bishop of London
My Lords, I thank the noble Baroness, Lady Tyler, for securing this timely debate. This issue is close to my heart. I draw noble Lords’ attention to my interests as set out in the register, specifically as a former government Chief Nursing Officer for England.
In my role as chair of a health inequalities action group, and as a Bishop with oversight of a diocese that includes some of the best hospitals in the world, I have had the privilege over the last few months of listening to a wide range of nurses. They have talked about their continued passion for high-quality nursing care, the wonderful teams of which they are a part, the innovations that are happening and their pride in their work.
However, they also speak about what lies behind the figures set out in the Royal College of Nursing report: about the impact of the last two and a half years of being tired and having gone into work day after day despite the fears for their own health and that of their families, and about how they had to innovate on their feet and go beyond what they had ever expected to do. They undertook roles that they had never imagined they would. They coped with staffing levels that were well below what was required and worked longer hours than they should have done. They did what was required, and we are grateful.
They went on to speak about the continuing pressures from increased patient dependency as a result of the pandemic; about the challenge of people presenting much later with progressive disease because of late diagnosis, so patients are sicker in our hospital beds; about the increased level of vacancies; about nurses who had gone home to other countries during the pandemic and not returned; and about nurses retiring early because of the pressure that they had been under. They spoke about how they would do what they have always done: make do, and do what is required.
We have heard some figures from the report. A couple that came to my sight are that, first, only 28% of respondents said the skill mix was appropriate to meet the needs and dependency of patient safety and, secondly, as noble Lords have heard, four in five respondents felt that care was being compromised while one in five said they were unable to raise their concerns. This all has a cost, not just to the quality of patient care, which we have heard about, or the deferred cost to the NHS. Nurses are paying the cost with their mental, physical and spiritual well-being.
As a Christian, I believe that each of us is precious and made in the image of God, with a sacred dignity and value that should be respected. Individuals are to be cherished, not just used and exploited. As a former government Chief Nursing Officer, I recognise the challenge of ensuring that the number and skills of those providing healthcare meet the needs of the population. I am sure the Minister will tell us how many more nurses are in the system, but that does not ensure that the workforce meets patients’ needs, particularly in light of the fact that patient acuity is growing. As someone who was given the objective of finding 60,000 nurses, I understand how this requires a whole-system approach, which is why I believe the Government should do what is required of them.
The Health and Care Bill gave the Secretary of State a duty to report on workforce systems and publish a report, at least once every five years, which describes the systems in place for assessing and meeting the workforce needs of the health service in England. NHS England and Health Education England must assist in the preparation of this report, if requested to do so by the Secretary of State. Will the Minister say when the Secretary of State will publish their report? Five years from now will be too late.
We heard during the passage of the Health and Care Bill that this accountability fell short of what many of us felt was essential, and the outcome of this shortcoming is seen in the royal college’s report. It is unfortunate that the Government did not take the opportunity in that Bill to embed accountability for workforce planning and supply with the Secretary of State. I believe this is the only way we could ensure that severe staff shortages and patient safety issues are resolved and addressed in a sustainable way, right across the healthcare system.
As we have heard, the Government need to ensure adequate funding for increasing the number of nurses whom we train and, as the noble Lord, Lord Lilley, says, this will take time. The truth is that one of the limiting factors is that our wards are not properly staffed today. It is hard to support and train nurses when the level of patient dependency is higher than the skill mix provided, and it is right that nurses are concerned about this. Will the Minister reassure the House that any overseas recruitment, to make up for lost time in training new nurses, is ethical?
As we have heard, we also need to retain nurses. That is where the most critical action is required at this point. The Government could consider a number of easy changes, which we have already heard about, to promote retention. There are some simple ones: for example, raising the payment per mile travelled in the course of a nurse undertaking their work. The Government could ensure that the pay rises given are realistic and that there are adequate funds for continual professional development and clinical supervision. I also hope that they could put in place clear mechanisms for staff to raise their concerns when staffing levels are not good enough. No nurse wants to work an understaffed shift: there is a cost to them and to their mental health and spiritual well-being. If a nurse is unable to raise that concern, they are even more conflicted.
We have asked much of our nurses over the last two and a half years, and they have done what is required. I hope that the Government will now do what is required of them.
Baroness Bennett of Manor Castle (GP)
My Lords, it is a great pleasure to follow the right reverend Prelate the Bishop of London who, together with the noble Baroness, Lady Tyler of Enfield—whom I thank for securing this debate on the report—have covered clearly the huge issues that it raises. I want us to take a broader, global view and then look at some of the structural issues behind the immediate reality in that report.
On the global view, the World Health Organization tells us that there is a shortage of 5.9 million nurses around the world; that is nearly a quarter of the current global workforce of almost 28 million. The biggest shortfalls are in low and middle-income countries, notably in Africa, Latin America, south-east Asia and the eastern Mediterranean. I agree with the noble Lord, Lord Lilley, that we in the UK should not be taking people from other countries, particularly ones with a nursing shortage. We should be training in the UK more nurses than we need. As a wealthy country, that should be our responsibility.
The International Council of Nurses says that behind this shortfall are many structural problems, including low pay, poor conditions and—remembering we are talking about the global scale—inadequate training availability. I note that McKinsey & Company did a study which found that, in five of six nations surveyed—the US, the UK, Singapore, Japan and France—one-third of nurses said that they were likely to quit in the next year. This is not a problem simply contained within the UK.
Of course, Covid is a huge factor here; the WHO estimates that about 180,000 healthcare workers died from Covid, many of them no doubt occupationally exposed between January 2020 and May 2021. Many others would have been harmed by long Covid, burnout and mental ill-health from the difficult conditions they were facing. Looking back to 2021, a long-term study by JAMA, a US research network, found that female nurses were twice as likely as women in the general population to commit suicide. That is a very disturbing statistic.
The noble Baroness, Lady Tyler, set out very clearly that we have a problem in the UK; the Government have stepped up recruitment, but it is not even keeping us at the levels of staffing we have now. There are aspects of this job that are enormously, immensely difficult. There will always be people needing care at all hours and on weekends. It is not possible ever to make this a nine-to-five job for many people.
Nurses and midwives have to deal with tremendously difficult situations. I think of a student midwife testifying about being on a work placement in a delivery room which had just had a stillbirth. She was left, as a student, comforting the mother while other professionals in the room looked after the medical needs that needed to be cared for. Think about the fact that that student midwife is now paying to be in that situation. To study as a student midwife, that is what you do: you pay.
My thesis, which I want to explore a little today, is that the underlying structural issue is that nursing and midwifery as professions are profoundly undervalued. That is why we find ourselves in this long-term global situation. I am drawing on another Royal College of Nursing report from last year, titled Gender and Nursing as a Profession: Valuing Nurses and Paying Them Their Worth. I note that in the UK—I think this is broadly reflected around the world—this is one of the most gender-segregated professions; only about 10% of nurses are male. As this report notes:
“Nursing suffers from a historical construction as a vocation”.
Individuals, usually women, were seen to enter it because they had a calling, and the salary was almost incidental; it enabled them to keep pursuing that calling as it was just enough. We know that many nurses feel this and that, through the pandemic and at all times, they display huge amounts of good will, working far beyond their paid hours and in very difficult conditions, often without financial reward.
We have to go further even than thinking about the gendered construction of nursing. The question here is the gendered construction of care. As the RCN report I am citing says, care is seen as
“a naturally feminine skill or characteristic”
that sits opposed to professional skills and qualifications. But being able to care for anyone in even the most difficult situation is an emotional labour. This should not be taken for granted. It should be properly recognised and remunerated.
In the UK we are in a position to provide potentially global leadership. The Government should like this, as I will say that we were historically world-leading in the nursing profession, with Mary Seacole, Florence Nightingale and many other names I could cite. We helped establish the global pattern for nursing as a profession. Of course, the NHS as a large single employer has the potential to turn this situation around and truly acknowledge the contribution nurses and midwives make.
Yet over recent years we have seen austerity suppress wages. Our heavily suppressing the ability of trade unions to act in the UK has also had a huge impact on wages. It is interesting that, as the RCN report notes, there is very
“little variation in earnings across the nursing workforce”—
among registered nurses—
“despite the wide range of roles and responsibility”.
There is a huge undervaluing of all levels, but particularly the highest levels.
I am out of time. I wanted to comment on how, although only about 10% of the profession are men, they occupy 20% of the highest-paid roles, but I will leave the exploration of that for another day. I finish with a little thought experiment for your Lordships’ House. Bankers are paid an awful lot more than nurses. Why?
Baroness Brinton (LD) [V]
My Lords, I congratulate my noble friend Lady Tyler on securing this important and timely debate and her excellent introduction to it. Its content is perhaps no surprise to many of us who have spoken so far. Our nursing workforce continues to face unbelievable pressures in their day-to-day roles. Supported by many other clinical and non-clinical NHS staff, nurses say that the NHS must staff for safety and for effective care.
The right reverend Prelate the Bishop of London spoke movingly from her own experience and deep knowledge of the issues that nurses face. I pay tribute to all of our NHS staff, who face the most severe difficulties at the moment. The Government seem to have glossed over these in their post-pandemic policy of, “Let’s just move on”. I hope that the Minister will respond to the questions raised by other noble Lords.
The RCN report rightly looks at the impact on its members, and it makes harrowing and concerning reading, especially on the lack of enough staff on duty on a regular basis, as well as the personal comments of those who have left through burnout. The Royal College of Emergency Medicine’s Beds in the NHS report shows that the NHS needs 13,000 extra staffed beds—the emphasis on “staffed” is important.
The pandemic was an emergency, but long before 2020 we were well below the OECD average for staffed hospital beds, and some of us have been raising concerns about staffing and beds for well over a decade. The current OECD data, which covers 2017-20, shows that the UK has 2.4 beds per 1,000 inhabitants; France has 5.8 and Germany has 7.8, while Korea and Japan have over 12. To repeat, the UK has 2.4—we have lost 25,000 hospital beds since 2010. Of course, in referring to hospital beds, we mean staff as well.
The pandemic has shown us the consequences of having bed occupancy at 95% early in 2020, but the underlying problems remain. The front line of this crisis in hospitals is the ambulance services and A&E departments, but we delude ourselves if we look at only the data. The workforce is absolutely critical, and many noble Lords have spoken about how important it is to plan properly for our nursing workforce. They have mentioned the Health and Care Act and the Government’s apology for workforce planning, including their assertions that they may not publish the workforce plans in full. I echo the questions seeking to understand why that is the case.
Nurses’ role has changed greatly over the last 40 years, and their high level of education and training means that the skills they offer can help to take the burdens off doctors and other clinicians, who bore them alone in the past. Specialist nurse practitioners have transformed the lives of many with long-term conditions—I include myself in that. Community nurse roles have also changed, but their current workload means that their real benefit of having time to talk to, listen to and understand the needs of their patients at home, and then to be able to signpost extra help or resolution, is under real pressure.
So it is good that the Government have increased the number of nurse training places, but it is less good that it is still not enough, given the number of retirements and staff leaving through burnout. The King’s Fund report on the NHS workforce makes this point very strongly, noting how much the UK will have to rely on international nurses. The noble Lord, Lord Lilley, made some interesting points on international recruitment. He has specific concerns about 4,000 nurses coming from poor countries, and he is absolutely not alone in that. But there are some more ethical overseas arrangements: my local trust, West Hertfordshire Hospitals NHS Trust, had an arrangement with hospitals in the Philippines whereby newly qualified nurses would come for a period, usually of five years, to gain some extra qualifications and then return home highly qualified. Even so, while they are away, their country does not have the skills for which it trained them.
Have the Government achieved their targets, set out in their elective recovery plan, which pledged to recruit 10,000 international nurses by April 2022, and are they encouraging the type of partnership that I just described? As my noble friend Lady Tyler said, retention is absolutely vital too. What plans do the Government have to tackle retention? This is about pay, the work environment, bullying, discrimination, more leadership and support for ethnic-minority staff facing discrimination and bias, all of which we have had reports on in recent months.
The noble Baroness, Lady Bennett, made an important point about the gender construction of nursing and, indeed, care. She is right that we undervalue and underpay those in caring nursing roles. That too needs to be re-evaluated, not just by government but by society. We should not have health staff caring for people’s personal needs while on the minimum wage. There is also pressure on nurses with a lack of doctors, so we need to note that the Secretary of State for Health and Social Care has acknowledged that the manifesto pledge to have 6,000 more GPs in England by 2024-25 is not on track. Similarly, the NHS target to fund 26,000 additional roles to ease the pressure on general practice is unlikely to be achieved by that same date. That pressure causes further pressure on our nurses.
Cancer targets are still being missed every month, and waiting times remain sky high. The NHS does not think that it can get them down in the next year, despite the Government promising performance returning to pre-pandemic levels by spring 2023.
Finally—news hot off the press—today there is monthly data for May on trusts achieving the target of waiting four hours or less in A&E. The average for achieving four hours or less is now 60%. The worst three are my own local hospital, West Herts; Barking, Havering and Redbridge; and Torbay and south Devon, which achieved between only 31% and 37%. Those figures alone are shocking, but what sits behind them is a shortage of nurses, doctors and other healthcare staff writ large. I hope that the Minister can respond to these concerns and ensures that we will have a nursing profession that is fully staffed, fully trained and fully supported, as they do their absolutely vital job in our NHS.
Baroness Merron (Lab)
My Lords, I start by thanking our nursing workforce and, indeed, the whole health and social care team. I congratulate the noble Baroness, Lady Tyler, on securing this important and very timely debate, and thank her for the way in which she set out the issues. It is important that we are considering them today, given this report. I also thank the Royal College of Nursing for this comprehensive report, which I believe shines a real light on the realities that are being experienced by the nursing team and patients. It produces a very loud red flag for the future, which I am sure the Minister will address. The Nursing and Midwifery Council also helpfully shared its annual registration data, cited in the report. I shall refer to that later.
The key message coming through from this debate, as has come through so many times, is the question of whether the Government have it right on workforce. I am sorry to say that, on this occasion as on previous occasions, the answer is no. This is about having the workforce to do the job. It has been debated numerous times in your Lordships’ House and in the other place. Your Lordships’ House made its view known very clearly that any organisation worth its salt—that certainly includes our National Health Service—would undoubtedly have in place a workforce plan for now and for planning ahead, looking at retention, recruitment and training, and all the many complexities involved. Yet within the Health and Care Act we did not have that commitment.
I will refer to the survey findings, which come in the context of record waiting lists and 50,000 registered nurse vacancies. The report refers to the fact that the UK’s exit from the EU and the Covid-19 pandemic have both highlighted and worsened long-term problems with workforce supply in health and social care. However, the report also says that this is nothing new. For many years, nursing staff have been shouting about the impact of growing staff shortages and the rising demand on their ability to deliver care that is safe and effective. The report argues that the impact of these pressures is now “beyond concerning”, with patient safety, care outcomes, staff retention and staff well-being affected.
On this point, I was glad to hear from the right reverend Prelate, who spoke of her experiences of talking to nurses and rightly reminded us of the positive side: nurses’ passion for improvement and service, and their commitment to delivering for patients. The right reverend Prelate also rightly spoke about the pressure on nurses. I wonder whether the kind of commitment shown to us by nursing teams means that their situation is constantly overlooked. I believe that there is a great tendency for them to be taken for granted because, as the right reverend Prelate said, they will always deliver.
From the report, we know that
“staffing levels are compromising care”
and
“that there are not enough registered nurses on shift”.
There is also a greater intensity of nursing care required by patients. This highlights that we have a worsening situation, not one that is static. This once again makes the case for proper workforce planning that can move with the times. I anticipate that the Minister will refer to the pandemic as being one of the greatest pressures. While that it is true, the report also said:
“Going into the … pandemic … 73% of nursing staff surveyed … said that staffing levels on their last shift were not sufficient to meet all the needs of the patients safely and effectively. In 2022, this has risen to 83%.”
This is not a new problem; it has been exacerbated but it would not be right to refer solely to the impact of the pandemic.
We have heard a number of the key findings, but the one that really strikes me is this:
“Only 25% of shifts had the full number of planned registered nurses on shift.”
Linked to that, 81% of those surveyed
“felt that patient care being compromised was due to not having enough registered nurses on the shift”,
and yet one in five said
“they felt unable to raise their concerns.”
This is a very dangerous cocktail to which I hope the Minister will have a response.
The report makes a number of recommendations, and we have had a number of proposals in the debate today. I am interested to hear the Minister’s response to the recommendations of the report and the points raised within this debate.
As we know, the Government have announced an increase in the number of nurses, and that can be tracked back to a 2019 manifesto pledge. In addition to providing us with an update on this situation, it is worth reiterating the point made by the noble Baroness, Lady Tyler, on the comments of the Chief Nursing Officer for England, Ruth May, who said that while she welcomed the pledge, it fell short of what was actually needed. This will be the case because recruitment on its own is not the point; it is also about the vacancy numbers, the shortfall and the numbers of nurses that are leaving.
On that point, I refer to the information from the Nursing and Midwifery Council. When asked why people had left, they said the main reasons were too much pressure, poor workplace culture, struggles with increased workloads and a lack of staff. Could the Minister give us more information on when he will be able to share the 15-year plan for the workforce? When will it materialise, and how will it take all of these matters into account?
The report calls for a “credible, costed long-term” health and care workforce strategy. A nursing team is at the heart of this. I hope that the Minister will hear the points made in today’s debate, but also the previous calls for a proper workforce plan, which will be the only way we can meet the demands upon us.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
I thank the noble Baroness, Lady Tyler, for securing this important debate on the report published by the Royal College of Nursing on 6 June, regarding nurses’ experiences and thoughts about staffing levels. I also thank the noble Lords who contributed to the debate. I know that all noble Lords agree that nurses perform essential duties within our healthcare system and are an integral part of the NHS workforce. I think we all want to put on record our thanks for their considerable dedication and commitment to the NHS, particularly during the pandemic when they faced challenges never seen before. I would also like to thank nursing staff for sharing their personal experiences, and the RCN for its hard work and thorough approach in compiling this report. As my noble friend Lord Lilley said, nurses deserve our gratitude and our sympathy.
The Government have read closely the points raised in the report, and although there are some that we accept and are working hard to address, there may be other areas that we question. Overall, we welcome the publication of the RCN’s findings and the spirit in which the report was conducted. There is much common ground between the Government and the RCN, including our shared aim to have a well-supported nursing workforce.
Let me begin by addressing some of the concerns raised in the report. The report was critical of the levels of safe staffing in hospitals in England. There is no single ratio or formula that can calculate the answer as to what represents safe staffing. It will differ within an organisation, and reaching the right mix requires the use of evidence-based tools, the exercising of professional judgment and a multi-professional approach. In England, the responsibility for staffing levels sits with clinical and other leaders at a local level. Providers should ensure that there are sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of the people using the service at all times. Staff should also receive the support, training, professional development, supervision and appraisals that are necessary for them to carry out their roles and responsibilities.
On domestic nursing recruitment, this Government are committed to increasing our nursing workforce, and one of our highest priorities is ensuring that we have a strong and steady supply of new nurses. As many noble Lords acknowledged, we have made the commitment to increase nursing numbers by 50,000 over the duration of the Parliament. We are well on our way to achieving this, with nursing figures now 30,000 higher than in 2019. This is a major level of growth in the nursing population, and to achieve it we need to look at every route that we can: domestic supply, international supply and improved retention. We have invested heavily in the domestic routes to nursing, broadening and diversifying the available routes, including apprenticeships, to offer opportunities to those who may not be able to go to university. This is in addition to the traditional university undergraduate and postgraduate routes into healthcare. We saw around 43,000 applicants to nursery and midwifery courses at the January application deadline, which is an increase of 25% compared to two years ago. This is supported by the introduction of a training grant of at least £5,000, given to nursing, midwifery and allied health professional students.
We have to acknowledge, as many noble Lords have said, that demand is outstripping supply. If we look at the bigger picture, we see that there are a number of reasons for this. We are living longer, and we are more aware of issues such as Alzheimer’s and dementias in those who live longer. We are also far more aware of mental health and its diversity. For example, when I was taking part in a debate on neurological conditions and I asked my policy team to list all the conditions, they said there were over 600. We were never aware of that before, to that level of detail, and it shows that supply will always struggle to keep up with demand.
To support long-term planning, the department commissioned Health Education England to work with partners and to review and renew the long-term strategic framework for the health and regulated social care workforce to ensure that we have the right skills, values and behaviours to deliver world-leading services and continue high standards of care. I mentioned this a number of times in the debates on the then Health and Care Bill. The work is nearing its final stages and will be published before the Summer Recess. Building on this, we have commissioned NHS England to develop a long-term workforce plan for the next 15 years, including long-term supply and demand projections, and we will share the key conclusions of this work. I am afraid that I am not able to give a date for that at the moment, but we will do it in due course.
On well-being and the retention of existing nurses, we must acknowledge that the last few years have been some of the most difficult that health and care staff have ever faced, and they have risen to the challenge admirably. Through the NHS people plan and people promise, we are taking action to improve staff experience and retention. This includes investing in staff health and well-being support, promoting flexible working opportunities to allow nurses to balance their working life, and strengthening leadership and organisational culture across the NHS. The NHS planning guidelines for both last year and this year emphasise the importance of supporting existing staff. Boards, leaders and managers across the NHS are being supported to adopt a compassionate, inclusive approach and to consider the health and well-being of all staff as a priority, so that is a consideration in every decision in the organisation.
I will turn now to some of the specific points raised. A number of noble Lords spoke about international recruitment. We should remind ourselves that immigrants from the Commonwealth, and across the world, who came here after the war, saved public services in this country. We should acknowledge that. Such people play a vital role in this country, but I understand concerns about international recruitment and whether it is ethical. We published a revised code of practice for international recruitment on 25 February 2021 in line with the latest advice from the World Health Organization. Through this code of practice, we are ensuring the fundamental principles of transparency, fairness and promotion.
Most of our recruitment internationally comes from countries which train more nurses than they have places for. They do this deliberately as a way of getting foreign earnings and remittances and having better qualified staff. For example, the Philippines, Kenya and states in India do this. It is really important to acknowledge that, so I should correct noble Lords who say that we are depriving these countries of their people. They also have the opportunity to develop their care in a world-class system. In addition, we have worked with the WHO on the red-list countries but, if an individual from one of those countries applies, we are not able to discriminate against them in the way that noble Lords want us to. We do not go out and recruit staff from countries on the red list, but individuals from them will apply.
People talk about a brain drain, but I will tell your Lordships a story about a friend of mine. I will not say which African country he is from, but he said to me, “You white people in the West talk about the brain drain and patronise us but, if I stay and try to work in my country, there are very limited opportunities for me—so my brain will be left in a drain. I want the best for my family, and that’s why I want to move to another country.” Further, if a person’s politics are different from that of the leadership of their country, it might sometimes hinder their promotion. While we adopt ethical guidelines in our explicit recruitment, we have to be aware that we cannot block individuals from countries on the red list from applying. That would simply be discrimination; we should be quite clear about that.
On top of that, I am concerned about a slight inconsistency. I hear people saying that we have lost people from the EU because we left it, but at the same time they complain about international recruitment. What is it about mostly white Europeans that they do not object to? Why do they then raise concerns about non-white non-Europeans from other countries? Therefore, we have to make sure that we are not inadvertently coming across as discriminatory against people who are not from white Europe. We have to make sure that we have a global view, not a little white European mentality.
It is also important that we retain existing staff, and a number of noble Lords spoke about that quite movingly. The NHS has a retention programme, and it is continuously seeking to understand why staff leave. There is an NHS health and well-being framework that helps NHS organisations to create a sustainable well-being culture. We are also looking at ideas, and “We work flexibly” is one element of the people promise. In February 2022, NHS England and NHS Improvement published a flexible working definition to help people balance all those various demands on life. Becoming a more flexible, modern employer will help us to recruit and retain people more effectively, and we see this as important.
My noble friend Lord Lilley asked about rationing university places. As with all degree subjects, unfortunately not every applicant is of the required standard to become a nurse and this means that there is sometimes a gap between applications and those accepted on to programmes. However, we had a record number of acceptances in 2021—a 28% increase versus 2019—achieved through offering non-repayable grants and investing £55 million in expanding capacity.
The right reverend Prelate raised the issue of staff raising concerns. The Government support the right of staff working in the NHS to speak up and raise concerns, and we take it very seriously. We have the National Guardian and the Speak Up direct helpline and website, and there are positive signs. The Freedom to Speak Up Index, the key measure of speaking up in the NHS, has improved every year since 2016 and the Government have enhanced the legal protections available to prohibit discrimination against job applicants.
I am afraid that I am running out of time, but I will try to answer as many points as possible. I will also go through Hansard and I commit to write to noble Lords.
The noble Baroness, Lady Bennett, mentioned staff morale. There is a comprehensive emotional and psychological support package which includes a health and care staff support service, including access to 40 mental health hubs around the country, which provide outreach and assessment services to help front-line staff. However, we know that a number of measures will be required—flexible working, mental health support and others—and it is really important that we look at this in its completeness when we look at these issues.
On the workforce, as I said, we have a number of different plans, including the Health Education England 15-year plan. On top of that, rather than a top-down system from Whitehall, sometimes you have to look at local services. ICBs, trusts and others will all have their own workforce goals and ambitions. We must make sure that it is not all top-down in a sort of Soviet way. We have to look at local discretion and the way we address this.
I hope I have answered many of the points raised but, on those I have not, I will write to noble Lords in the usual way. I thank the noble Baroness, Lady Tyler, for raising this debate. She is a fellow alumnus as we went to the same school, but at different times, as she likes to remind me. This is a hugely important area. I will close by reiterating the Government’s commitment to our workforce and to ensuring that staff feel well supported in their professions. I look forward to future debates on this subject and continuing to ensure that we have an NHS workforce that is fit for the future—and that is diverse. It is shocking, when you think about the contribution of many people who have come to this country from outside Europe and who are not white, that if you look at the top layers of NHS management you will see a distinct lack of diversity. That needs to be addressed, as well as all the other issues we have discussed today.