Health and Social Care

Baroness Finlay of Llandaff Excerpts

Thursday 24th November 2016 Lords Chamber

Moved by

[Baroness Finlay of Llandaff]

To move that this House takes note of the implications for the health and social care workforce of the result of the referendum on the United Kingdom’s membership of the European Union.

[Baroness Finlay of Llandaff (CB)]

My Lords, I am grateful to have been able to secure this debate. I will use the term EU collectively to cover the non-UK parts of the European Union and the European Economic Area, as only 230 health and social care staff come from the latter.

We spend about the same percentage of our GDP on publicly funded health as is spent on average by the 14 nations who acceded to the EU before 2004, yet an Organisation for Economic Co-operation and Development report published today shows that we are the sick man of Europe for doctors and beds. Our heart attack and stroke survival is mediocre, cancer survival poor, we desperately need more doctors—Germany has 50% more than us—and we need more, not fewer, beds.

Our struggling health and social care sector has unfilled posts, increased demand and funding pressures. Until now, reciprocity of qualifications and free movement has brought us Europeans, from the top-flight academics and clinicians with unique skills to the lowest-grade care workers. Now, with Brexit, we must decide what we want to negotiate for.

Twenty-nine major health and social care professional bodies, royal colleges, unions, employers and skills and learning organisations have formed the Cavendish Coalition to ensure a sustainable workforce supply and thereby maintain excellent standards of care.

Around 160,000 current NHS and social care staff are EU nationals—58,000 in the NHS and 90,000 in social care, which is 6% and 7% of the workforce respectively. Most are in posts that would otherwise have gone unfilled; they are essential to sustaining services and to our research enterprise. Unless we respect staff at every level and the NHS and social care become good employers, we will not attract the next generation here into the care sector.

Salary alone is not a proxy for worth. “Worth” is knowing that you are valued in society and respected as doing an important, complex and at times difficult job because you have unique skills. After Luxembourg, the UK is the largest net importer of healthcare professionals who qualified in other parts of the EU, particularly in some specialist NHS trusts such as the Royal Brompton and Harefield, where more than 15% of staff are from the EU.

Let me start with my own profession, doctors, of whom a quarter overall are non-UK graduates. Some 11% of registered doctors in the UK—just over 30,000—gained their primary medical qualification in another European country. That is one in 10 of our NHS doctors. We are so under-doctored that 40% of advertised consultant vacancies are unfilled, usually through lack of suitable applicants. Well over a quarter of current consultants report,

“significant gaps in the trainees’ rotas such that patient care is compromised”.

The very welcome increase of 1,500 medical student places will take a decade or more to feed through to supply specialists. In the meantime, we must continue to recruit from outside.

What about beyond medicine? Overall, the NHS vacancy factor is running at 6%, particularly in nursing. Almost a fifth of midwives in parts of London—it is 6% across the UK—are EU nationals. We rely on Europe. There is already a tension between safe levels of nursing staff and financial pressures against using agency staff. I know my noble friend Lady Watkins will address the nursing workforce further. Access to dentistry is also already a problem but I will not the steal the thunder of the noble Lord, Lord Colwyn. We rely on physiotherapists from overseas, 7% of whom are EU qualified. As service demand grows, so recruitment becomes more difficult. The Chartered Society of Physiotherapy—I declare my interest as president—has workforce modelling showing we need at least 500 extra physio student places each year for the next three years.

In social care, one in 20 social workers and more than one in 10 other professionals, particularly nurses, are from the EU, but the greatest crisis looms in domiciliary social care. Turnover rates are already incredibly high: currently well over one in three, 37%, leave their role each year. This churn leads to lack of continuity and concomitant problems. When will the current workforce be told they have indefinite leave to remain—with their children? We cannot continue to defer such assurance which must apply regardless of how long they have been in the UK.

This workforce provides care and support to aid people’s independence, and prevent ill health and unnecessary hospital admission. They care for people when they are most vulnerable. The mood music is positive but that is not enough. These people we depend on need legal certainty and we need that clarified quickly to mitigate the risk of staff leaving. Such rights, including any cut-off period post-Brexit, must be communicated in a way that actively supports community cohesion and reverses the detestable aggressive and xenophobic attitude seen in recent months. If EU workers continue to feel unwelcome and decide to leave, some NHS and social care services will simply have to put up a closed sign.

On staff numbers, I focused on the large number of EU nationals working here in health and social care but more than double that number are non-UK, non-EU staff. Blanket calls for tighter immigration controls overall will simply cripple NHS and social care at a stroke. Make no mistake: the current five-year rule for a permanent UK residence card would exclude thousands. More than a quarter of all adult social care workers are from outside the UK.

The current tier 2 visa system needs review. With a fixed quota of tier 2 work permits, applicants score more points for higher-paid jobs; it is not a level playing field. Financial services staff enter in preference to low-paid health and social care staff, yet we desperately need the latter. Will the Government undertake to urgently revise both the residence requirement and the tier 2 visa points for future health and social care staff?

We must continue to recruit and retain health and social care staff from the EU and beyond while we try to increase domestic supply. To fill vacancies, more specific occupations than just nurses and midwives need to be added to the Migration Advisory Committee’s shortage list. Yet a word of caution: we must not compensate for fewer Europeans by selfishly raiding professionals from developing countries. That would further destabilise our world.

The Medical Training Initiative is a mutually beneficial scheme, run by the Academy of Medical Royal Colleges. It gives junior doctors from all over the world the opportunity to work and train here under a tier 5 visa while giving trusts a high-quality, longer-term alternative to locums for filling rota gaps. Will the Government support extension of this proven effective scheme?

We need special arrangements for Ireland. Professionals flow freely between north and south across the land border. Many doctors in Northern Ireland graduated from a university in Eire. Are the Government looking to Ireland to be our friend at the table when we leave the EU, in the same way that Norway relies on Denmark?

In employment policy and practice we benefit from remaining in concert with Europe, not disconnected from advances that safeguard staff such as TUPE protection during service reconfigurations and the manual handling directive. The European working time directive is in UK law and junior doctors’ working hours now average 48 a week. No one should contemplate increasing hours post-Brexit but we could introduce more flexibility over rest breaks and work patterns to enhance work/life balance and improve training. This can be done if and only if there is no tightening of immigration numbers in health and social care.

The General Medical Council would like the opportunity to test the competence of all doctors coming to practise here from Europe, to check they meet the same standards as UK graduates and so better protect patients. To make this possible, will the UK Government amend the GMC’s powers as set out in the Medical Act 1983? Will regulation and training across professions be integral to Brexit negotiations?

Currently, medical and research staff particularly benefit from training experience in EU countries. Will the Government remember to keep the door open for UK doctors wishing to work in the EU once the UK is no longer a member state? It is not only doctors but nurses, physiotherapists and all our other professionals.

Let us not forget biomedical research, in which we have been a world leader. Our global collaborations keep us ahead of the field. To date, the UK has been a net beneficiary of European research funding. From 2007 to 2013, we received €8.8 billion but contributed only €5.4 billion. The Prime Minister’s announcement this week of an extra £2 billion research development spend is incredibly welcome but we need to be able to employ the right talent to optimise research output.

Overall, one in five of the UK’s academic community is an EU national, although more than three-quarters of the winners of the prestigious BMA medical research grants this year originate from other European countries. Brexit risks our being excluded from the Erasmus and Marie Curie research training schemes and from invaluable collaborative experience in communicable disease management at the European Centre for Disease Prevention and Control. We cannot exclude ourselves from this expertise. Infection and toxins know no political barriers. World epidemics are and will remain a looming threat to our nation’s health.

The impact of Brexit, with falling scientific recruitment and disrupted Horizon 2020 research, was reported in Nature in August. Is the Government’s plan that we try to remain part of EU research systems and contribute funds to the European grants schemes so that we can apply for them? Will the Government ensure that our future regulatory framework enables cross-border research and clinical trials, even though we may well wish to be more nimble in the newer research fields, such as genomics?

The challenges are huge. To grow our own we must attract people into health and social care. That means valuing staff at every level, both in the workplace and in society, for the complex job they do and the personal risks to which they are very often exposed. Society’s attitudes to the sick, the vulnerable and the frail must change, and those who care for them should have proper working conditions—not thanklessly be worked into the ground. Only then will we attract our school leavers into caring roles and only then do we stand a chance of being self-sufficient in health and social care. I beg to move.

--- Later in debate ---

[Baroness Finlay of Llandaff]

My Lords, I thank everyone who has spoken in this debate. I wish I could go through each contribution individually but time will not allow that.

I am very sorry that the Minister thought the debate was a moan, because it really was not. I do not think anyone here has moaned; rather, everyone has laid out facts and figures to try to demonstrate the problem that we have to tackle. The Minister spoke of huge opportunities, and it is to be regretted that no one who campaigned to leave was here to spell out what those opportunities might be, which they could have done. I offered up a couple and asked a question about them, but got no response. I look forward to the Minister perhaps writing to me in future and answering them—simply about the GMC’s powers and so on.

The debate has demonstrated that there is indeed a gaping gap. We risk haemorrhaging staff. A perfect storm is brewing, as has been spelled out today. Yes, we need to train our own staff, but this is not just about training places; this has to go right back into schools and across society to change attitudes, as has been said, so that care is viewed as esteemed work to go into. Our research cannot happen unless the regulations and routes for collaboration are in place and wide open and people feel welcome. I am sad that we have had no assurance on that today.

The phrase “addicted to overseas staff” is absolutely correct. Perhaps this debate has demonstrated that cold turkey is going on, as we realise that they are not going to be there in future and we cannot carry on with that addiction. The heart of our country is indeed at threat. The prejudice that people have experienced has been ugly. We are at a tipping point if we are going to lose that 5% to 10% of qualified European staff, who are certainly feeling uncomfortable and getting cold feet about remaining.

To close, I simply wish to say that I do not believe this was a negative debate. People were trying to be very constructive and lay out the problems. Unless you know the problem, you cannot find a solution. We cannot simply come out with bald statements along the lines of, “Don’t worry, it’ll be okay in the longer term”.

I thank most sincerely everyone who contributed. I beg to move.

Motion agreed.