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.