NHS and Social Care: Impact of Brexit

Baroness Watkins of Tavistock Excerpts

Thursday 21st July 2016 Lords Chamber

Moved by

[Baroness Watkins of Tavistock]

That this House takes note of the implications of the European Union referendum result for government policies on ensuring safe staffing levels in the National Health Service and social care services.

[Baroness Watkins of Tavistock (CB)]

My Lords, we have spoken at length about the uncertainty following the decision to leave the EU. While negotiations take place in the coming months and years, we must not forget that business continues as usual in the health and social care services, where staff care for our loved ones 24 hours a day, seven days a week. Two big stories appeared in the papers at the beginning of the week. The first was about nurses and plagiarism in universities and the second, much more cheerful one, was an opinion piece in the Daily Telegraph by Simon Stevens, the chief executive of NHS England, with which I broadly agree. However, I want noble Lords to know that I had written this speech before I read his piece, so it is not plagiarism.

I declare my interests as listed in the register, in particular as a registered nurse in both the adult and mental health domains, a member of the Royal College of Nursing, emeritus professor of nursing at Plymouth University and the chair of the peninsula CLAHRC in the south-west. I am delighted to congratulate our current Minister, who is to continue in his role representing health in this House. I will use nursing as a lens through which to articulate my questions, but I believe that the majority of the issues raised affect all those working in our NHS and social care services, and of course the clinical research community.

The decision to leave the EU leaves us with serious uncertainty on the current and future supply of the lifeblood of our NHS, the private, voluntary and social care sectors—namely, the workforce. That decision, together with what I had written was a proposed move to a loans system for nursing and other healthcare students, could pose a dangerous threat to the quality of patient care. This morning the Government announced that they will move to that loans system, and I will return to that later in my remarks.

In March 2016, the HSCIC figures for England showed a headcount of nearly 320,000 nurses and health visitors, 26,000 midwives, nearly 20,000 ambulance staff and almost 150,000 scientific, therapeutic and technical staff. At the same time in Scotland the headcount was approximately 60,000 nurses and midwives. Out of those numbers it is estimated that between 5% and 10% of the staff working in these roles are from other EU countries, clearly with variations by professional group. There are currently more than 33,000 nurses who trained in the EU registered to work in the UK and in 2015-16 alone there was an increase of 9,000 EU-qualified nurses on the NMC register. The latest GMC figures show that more than 30,000 doctors are working in the UK whose primary qualification is from another EU or European Economic Area country.

EU nationals play an integral role in delivering safe, high-quality care now more than ever, and our NHS is particularly dependent on these crucial staff. Yet EU nationals already working in these services are worried about what their future holds and whether they will be able to continue to make a valuable contribution to our society. Likewise, patients and users of our NHS have the same questions. Let me be clear: these professionals are highly valued and we simply cannot do without them.

Noble Lords may have heard of incidents since the referendum in which some health professionals from outside the UK have been subjected to racial abuse while caring for patients. No member of staff should have to tolerate abuse in the workplace at any time. Ambiguity around the immigration status of health professionals is not helping matters, and I ask the Minister to look at how quickly we can reassure them. Staffing levels, recruitment and the retention of nurses in the NHS continue to lag behind the number of staff we need to guarantee the highest levels of safe care for people using the NHS. In Wales, and soon in Scotland, staffing levels are enshrined in law. I urge the Government in England to look at this option carefully for public protection in the post-Brexit era.

Following the Francis inquiry into standards of care in Mid Staffordshire, the public were assured that financial considerations would not be put above the need to provide high-quality care and maintain good standards, which of course are dependent on the number of staff employed. The relationship between the staffing ratio of nurses to patient outcomes is well evidenced through international research: the higher the number of nurses, the better patient outcomes are, including patient readmissions after discharge. Yet mental health services in particular suffer from chronic understaffing and the number of specialist mental health nurses has fallen by 10% over the past five years. There are strong arguments for adequate nurse-to-service-user ratios to ensure the proper development of therapeutic relationships in mental health services. It is also clear that the higher the number of experienced registered nurses on duty, the less restraint and seclusion are used, which I argue is an indicator of quality care. While the introduction of the new nursing associate role in England is widely supported, current research suggests that the role will be no substitute for registered nurses, but a supplement to care delivery.

Many people who voted to leave the EU did so because they believed that extra resources would be allocated to the NHS as a result of savings in EU contributions. I argue that further funds should be found to train, develop and retain professional staff in the NHS and social services. In this context, I return briefly to what was the Government’s proposal but is now going to happen: the replacement of NHS bursaries by student loans for nurses and other health professionals. This idea began before the result of the referendum was known. It is an increasingly risky move during this period of turbulence through all the changes with the EU. But now that it has been announced, we must make the best of it. Nurses are struggling to make ends meet as it is. We have heard of some student nurses using food banks. Any reforms to the student bursary structures need to ensure that tomorrow’s workforce is not saddled with a lifetime’s debt, which the Government have already acknowledged is unlikely to be fully repaid given the average nurse’s lifetime earnings.

The Royal College of Nursing found that 40% of London’s nurses expect to leave the city by 2021 because housing costs are so high. The additional costs of even small monthly student loan repayments for nurses will make life harder for them despite working full-time. Tomorrow’s nurses serve as a good example of the very people our new Prime Minister wishes to consider when making future policy decisions. I, really more than anybody else, hope that the introduction of the loan does not prove to be a mistake. Any new model of funding should have been piloted before we ran it right across England, to ensure that it would result in an increase in the number of nurses taking up training places.

However, as a pause is not feasible, which many noble Lords know I would have liked, there remains a critical need to ensure the security of the future workforce supply—a task that I believe has become more difficult since 24 June. In that light, I shall touch briefly on three areas of risk on which there is widespread consensus from all organisations in the nursing world.

First, will the Government commit to protecting the postgraduate pre-registration courses that are so valued by employers and enable some of our best and brightest graduates to fulfil specialist careers in the NHS? Perhaps we should develop something similar to Police Now or Teach First. Secondly, will the Government commit to measures to support students who might otherwise be deterred from joining courses, ensuring that childcare grants do not disadvantage single parents, and recognise the particular challenges facing some professions in areas of nursing where student recruitment is still not buoyant, such as podiatry and learning disability nursing?

Thirdly, will the Government recognise the extra costs that healthcare students incur from essential aspects of their courses, in particular the travel and accommodation expenses associated with placements, particularly in rural areas, occupational health and uniform requirements? Linked to this, will they fund universities directly to purchase high-quality placements for students, so that the placement money follows the student and does not get incorporated into core hospital budgets?

As we continue the transition to the new healthcare education funding system in England, we need to look beyond the immediate implementation of these reforms to the longer term. The retention of staff within the NHS is a far greater challenge than recruiting students to join undergraduate programmes. There is a clear case for the Government to consider “forgivable loans” for students who go on to work in the NHS for, say, three to five years—a cost, of course, but one that could well be outweighed by savings on agency staff and recruiting from overseas.

For all the debate on pre-registration education, which is entirely appropriate, perhaps a deeper concern for the future lies in an area where very little has been said: that of professional development funding—a silence that we must break if the future of the NHS and its workforce is to be safeguarded through the momentous changes ahead. Central to the implicit covenant we make with NHS staff is that we will support and train them in their jobs. This will become more important than ever as we ask them to deliver the extraordinary challenges that rapid shifts in technology, the genome project, changing patient needs and increased financial pressures demand.

Yet despite this, NHS England’s centrally distributed budget for ongoing training for more than three-quarters of the health professional workforce has been cut by 45% this year. There is no doubt that the cuts are affecting those professions that are predominantly female. Failing to fund in the areas that we need most in the future, such as return-to-nursing programmes, cognitive behaviour therapy skill development and district nursing, could have serious consequences, and we need to think about care delivery outside the NHS hospital box.

How can we expect our staff to deliver the NHS five-year forward view and the care our population needs if we do not support their continued professional development necessary to do their jobs? The simple truth is that the national strategic priorities of the NHS, on which there is widespread consensus, and the funding decisions on education and training do not add up. We all understand the financial pressures on the NHS but education and training must no longer be a soft target. We need to ensure strategic leadership so that short-term financial savings do not result in us not having an adequate workforce in the future. I seek assurances from the Minister that the Government will work with and not against the healthcare professions in such a review of looking at how to tackle this subject in the longer term.

I now turn briefly to one related topic. Since 24 June the need for a senior nurse in the Department of Health as well as a chief nursing officer at NHS England has become even more important. We must have a nurse leader to advise Ministers and others at government level, to represent the UK on the world stage and steer us through the challenges ahead during EU negotiations. Nursing is the backbone of our health and care system. Department of Health-based nurse leadership will make a vital contribution to the challenges that we have to face. One example will be to review the EU professional qualifications directive 2013/55.

Finally, I recognise that enormous questions need to be addressed following the EU vote. That is why I believe that healthcare professionals should be involved in any discussions affecting our health and social care services. It is only by working together that we will be able to chart a path of success through this new and rapidly changing landscape. The Government must act now to develop a coherent and sustainable workforce strategy for the future, and recognise the essential contribution of overseas staff alongside the pressing need to educate, recruit and retain a workforce from within the UK.

I look forward to contributions from other noble Lords, who I thank in advance for staying for almost the final debate before the Recess. I hope that the Minister will provide reassurance on the issues raised this afternoon. I beg to move.

--- Later in debate ---

[Baroness Watkins of Tavistock]

I thank the Minister for his response and his recognition that some of these issues need to be returned to in future as a strategy develops in relation to the Brexit discussions. This country has always worked with staff from across the world, as I was reminded this morning when I went to the Nightingale Museum and saw the wonderful new Mary Seacole memorial. She was a Jamaican nurse who worked with Florence Nightingale. We must not take as long as we have taken to recognise her to reassure EU staff working with us, otherwise they will leave very quickly and, more importantly, new people will not come from the EU to work with us because of the uncertainty.

I recognise the need to negotiate about UK nationals who live in other EU countries. However, a swift assurance to all EU health and care workers in the UK would serve to reassure not only them but the vast majority of EU nationals who actually live in the four countries of Great Britain. I therefore urge that we do not take too long to reassure everyone about the need to continue to have this mixed workforce, to get a proper continuing strategy for health and education in future, and to ensure that we not only train new nurses and doctors but give them continued professional development so that they want to stay in this country and become a core part of our retained senior workforce.

Motion agreed.

NHS: Unsafe Hospital Discharges

Baroness Watkins of Tavistock Excerpts

Wednesday 15th June 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, this is a difficult issue. You can lead a horse to water but you cannot make it drink. To some extent you have to rely on local people working together, and it is behaviour and culture that determine long-term sustainable improvement. If we try to force the pace beyond that at which local people are prepared to go, in the long run we may not make as much progress. In the first instance we hope that the STP process, involving all local people and giving them a framework for working together, will deliver the results we need. If it does not, we will have to revisit it.

[Baroness Watkins of Tavistock (CB)]

My Lords, could the Minister ask why the NHS has not considered funding nursing home places for people who are ready to be discharged for two or three weeks, so that they can have 24-hour care funded by the NHS while they prepare to move back home? People who live alone, in particular, are just waiting for financial assessments while reducing other people’s access to acute hospital beds, including young people who are routinely having standard operations cancelled.

[Lord Prior of Brampton]

My Lords, looking back over 20 years, the reduction in the number of what you might call step-down facilities—community hospitals and the like—has been a huge mistake. We lack step-down facilities. In America they are called skilled nursing units. The fact is that an acute hospital is not a good place to be for anyone once they are medically fit to be discharged; all the evidence suggests that it is more expensive but, more importantly, less good for the patient. I agree entirely with the noble Baroness that we need to explore avenues of discharging people earlier to nursing homes, community hospitals or, better still, back home with the right community support.

NHS: Hospital Overcrowding

Baroness Watkins of Tavistock Excerpts

Tuesday 15th March 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the demand on the health service is rising for many reasons, of which the growing population is clearly one. However, without the extraordinary contribution made to the NHS by people who have emigrated here from other countries, we would not have an NHS at all.

[Baroness Watkins of Tavistock (CB)]

My Lords, will the Minister comment on how we might prevent people going into hospital through much better structuring of community teams led by nurses? Last week, I was told at the Secretary of State’s conference on patient safety that the mean age of patients on a medical ward at Oxford was 83. When I was a ward sister, it was around 50.

[Lord Prior of Brampton]

My Lords, clearly it must make more sense to provide better treatment for elderly people in their homes, away from hospitals, particularly for those with often multiple long-term conditions. One of the tragedies of government policy since 2000—this goes across both parties—is that, although the rhetoric has been about moving care out of hospitals into the community, it has been extremely difficult to do it.

National Health Service: Nurses

Baroness Watkins of Tavistock Excerpts

Tuesday 26th January 2016 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, what consideration have the Government given to enabling people who want to study nursing as a second degree to have loans in the way that they will allow for those studying some STEM subjects? We have traditionally had mature entrants who are already graduates.

[Lord Prior of Brampton]

My Lords, we are still consulting on the details of this scheme, but I assure the noble Baroness that the loan scheme will be available for mature students doing their second degree as it is for those doing their first degree.

National Health Service

Baroness Watkins of Tavistock Excerpts

Thursday 14th January 2016 Lords Chamber

[Baroness Watkins of Tavistock (CB) (Maiden Speech)]

My Lords, I thank the noble Lord, Lord Turnberg, for tabling this debate, in which it is a great honour as a Member of this House to make my maiden speech.

My career started in 1973 as a nursing student in close proximity to this House at Westminster hospital where, on a more personal note, I was fortunate to meet my husband, a surgeon. I thank him for his support and encouragement in embracing my appointment to this House. Although I do not mean to be controversial today, I can assure your Lordships that this is difficult for me, having extensively argued the merits of investment in nursing versus medicine, surgery versus mental health, and acute care versus community care throughout the 40 years’ experience I have as a nurse and regular practice with a surgeon at home. In turn, this led me to a deputy vice chancellor role at Plymouth University, with responsibility for student affairs, including a range of health programmes. I have more recently been involved in chairing academy schools, working as a non-executive director in the NHS and the Aster Housing Group. I also undertake charitable work in drug treatment centres and in the care of older people.

I thank noble Lords on all sides of the House for the warm welcome that has been extended to me since my arrival and all the staff of the House for the assistance they have given me. I also thank my two supporters—my noble friend Lady Emerton and the noble Lord, Lord Kestenbaum—and my mentor, my noble friend Lord Patel, who tells me that he is watching this from India.

The vision for the NHS is for a modern, efficient and sustainable NHS where care and compassion matter. It has been argued that an integrated approach could both improve the quality of care for patients and improve productivity. Numerous studies have shown that an increase in the number of registered nurses in hospital and community settings is associated with clear benefits for patient mortality rates and other key metrics. Patient outcomes are enhanced if care is co-ordinated and, where necessary, delivered by registered nurses. If hospital admissions are to be reduced, rapid assessment in patients’ own homes from a range of healthcare professionals is vital. Yet are we doing enough to ensure that we are training sufficient numbers of healthcare professionals to achieve and sustain integrated care as outlined in our strategy?

In the early 1980s, as a “nursing officer for change”, I worked in a large mental hospital where over 1,000 beds were closed and replaced with community-based services. The key to the largely successful project was that all clinical staff were provided with further education and development to prepare them for the changes in their role. Community care is now the norm for those who have mental health and learning disability challenges, and most care is successfully delivered in a range of health and social care settings. I would argue that we are not so successful in providing acute healthcare intervention in people’s own homes, as evidenced by increasing admission rates to hospital, yet other countries successfully provide more care in the community. We hardly have an ideal situation at the moment.

Key to successful community care for people with the most acute medical problems and long-term conditions is the number and kind of nurses that are available to work in a range of settings, yet we know that we have an international shortage of qualified nurses which is estimated to be at least 20,000 in the UK alone, resulting in increased agency staff costs and, perhaps more important, reduced continuity of care. Happily, the number of nursing places in universities is set to rise this year, but for the next three years we will have the lowest output of registered nurses because of previous short-term cuts. The noble Lord, Lord Willis of Knaresborough, has indicated that we need to put training at the very heart of the NHS agenda, and that lifelong learning is essential. If we want a thriving healthcare structure, we must ensure that we have a workforce that is provided by the voluntary, social enterprise and independent sectors as well as the NHS. We need to recruit, train and retain care assistants, who provide support for individuals in their homes working with registered nurses.

In a recent letter to the Times, the noble Lord, Lord Hunt of Kings Heath, concluded that the NHS is currently remarkably robust considering the level of investment. I agree, yet as others have said today, funding remains relatively stable in real terms and the only way to resource the future is to redesign our service to meet future challenges. Nursing is pivotal to this. In the current situation, the role and complexity of nursing is poorly understood, especially the role of the registered nurse with a degree. I can assure noble Lords that degree-level nurses are not too posh to wash, but can do so only if they have enough time to do it with care and compassion, as well as overseeing others who can deliver care well. The Guardian recently suggested that NHS leadership is ailing, but pointed to the Florence Nightingale leadership scholarships as an area of good practice. We must provide more opportunities for leadership development to ensure a supply of competent leaders who are able to respond to changing demand and lead the redesign of services for a sustainable NHS.

I have argued that registered nurses are pivotal to greater NHS productivity. This will require valuing and investing in the profession not only in terms of education and opportunity but by demonstrating for tomorrow’s care workers kindness and compassion in employment terms, so that this, in turn, is reflected in the care they give not only to us in this House but to society at large in the four countries of the United Kingdom.