NHS: Long-term Sustainability
Lord Scriven Excerpts(1 day, 19 hours ago)
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Lord Scriven (LD)
My Lords, what a pleasure it is to follow the noble Lord, Lord Hunt of Kings Heath, who like myself is a former NHS manager and who clearly understands the difficulties and nuances of the future challenge of the NHS. I am also thankful to the noble Lord, Lord Patel, for this very timely debate.
The current performance of the NHS worries many and therefore needs to be improved urgently before it can be a stable platform for us to rise to the challenge of the significant technological and demographic changes that will take place if it is to become sustainable. The NHS’s current performance is distressing to say the least, despite the gallant efforts of many staff within the system. People in need of care and treatment are unable to see an appropriate medic or professional, with some waiting up to three years just to get on the NHS dentist list. People are waiting in the back of ambulances outside A&E for hours, while people waiting for a cancer diagnosis are not getting access to timely treatment, which can be life threatening, and people in great pain and agony are waiting far too long for planned operations. The Government have allowed this to happen and now try to placate the public with a list of office-generated statistics and playing catch-up. It is not good enough. People deserve far better than this.
Despite this picture of appalling failure by the Government, this debate makes us think very carefully about the future of our NHS. I am sure that the debate will be framed around two themes: one is how to make the NHS more productive, efficient, and innovative, while the other theme will be the wider context of the demographic, economic and social issues in which the NHS will have to work. The reality is both these themes will have to be addressed for a sustainable NHS.
Time today is limited, so I cannot go into depth about what is required across both themes, but I shall throw these issues in as a starter for 10. The 1948 orthodoxy on which the NHS stands has to be addressed, if we are going to see an NHS that can meet future need. For instance, why do we have a fixed view which is over 70 years old of what a hospital should be? Why are emergency and elective services always in the same building? Is it time to think more laterally about emergency hospitals and elective hubs? The model of primary care needs to be questioned. Why have we had the same model and front door system for over 70 years? This needs significant change, for those who need significant primary care needs due to comorbidities and those who occasionally dip in and out of primary care. Maybe a different type of service delivery is required, as the integrated electronic health record takes hold, with no longer just one model of GP and primary care access.
As technology, robotics, AI and data-driven services become central in predicting, planning and delivering healthcare, appropriate leadership skills at all levels of the NHS will need to be addressed to maximise the potential of these issues, as well as to minimise the risks. Is it time to end the leadership model based predominantly on managing efficient siloed organisations by moving to leaders who are experts in maximising health gain and facilitating community action to bring about complex change?
Societal issues, such as housing, education and the environment will have to be addressed, as the NHS does not work within a vacuum. A population that is ageing with comorbidities, and the balance between the working-age population and the non-working-age population—and, of course, climate change—needs to be addressed. Some key issues that we need to think about across government to support the NHS maximising health gain are supporting people to age with dignity and independence, tackling deep-rooted worklessness, and an absolute laser-sharp determination to narrow the health inequalities, as well as having a long-term and fully understood funding formula for both the NHS and social care.
All this will take long-term, focused action by government and society. I am not sure that the siloed structure of central government can deal with these challenges effectively at present. The approach must be a community health-based model, to maximise healthiness and improve health outcomes.
One simple way of supporting this would be for the Treasury to set up designated funds that can be used in communities and the NHS to invest for health. That would break down the problem of pretending we can move existing NHS budgets, which are mainly sunk, fixed costs, into prevention and reducing health inequalities.
Talking of funds, it is vital, as the noble Lord, Lord Patel, said, that we sort out, once and for all, the social care crisis. The NHS can never be sustainable if, as a nation, we have not dealt with social care funding. After the general election, I think it is the duty of all politicians, from all parties, to sit down and work out a cross-party solution to this difficult problem that has been left for far too long. We need to take a different approach and think about some fundamental questions if we are to have a sustainable NHS.
Anaesthesia Associates and Physician Associates Order 2024
Lord Scriven Excerpts(1 month, 3 weeks ago)
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Baroness Bloomfield of Hinton Waldrist (Con)
My Lords, I will speak very briefly in favour of these regulations. I am absolutely in favour of any way in which we can leverage the ability of our doctors to concentrate on what they want to do, and what they have been highly and expensively trained to do, which is to take responsibility for seeing, diagnosing and treating patients who are ill and in need of medical help. I am also in favour of trying to reduce the exorbitant cost of locum GPs, which bleed resources from the National Health Service—resources which could be much better spent elsewhere. Some of the Government’s initiatives, such as allowing pharmacists greater and more extensive advisory and prescribing powers, are also very welcome.
I have no philosophical objection to the concept of physicians or anaesthetists being supported by assistants, whether they are senior nursing staff or others, but I share the concern that the very term “associate” implies a greater degree of qualification than is actually the case. Two years’ training post a science degree does not a doctor make. Of course they should be regulated by an organisation which enjoys public confidence, so long as that in itself does not imply a greater medical qualification.
It is easier to prevent overreach in a hospital environment, where supervision in anaesthesia should be routine, but it is much harder in general practice. The reason I rise now is because my husband was seen by a physician associate when his throat failed to heal weeks after he burned it with a hot cup of coffee. After the young man had taken a photograph and disappeared up the corridor with his phone, allegedly to see a GP, he reappeared with an ominous pamphlet entitled “Suspected throat cancer” and suggested an urgent appointment at the John Radcliffe Hospital. I am pretty sure he was not trained to be the bearer of such bad news. So undoubtedly physician associates need to be regulated, though I acknowledge it was better this way round than ignoring something and saying that there was no issue to be dealt with when there might have been.
We have 14 GPs in our local practice, in a small town in Oxfordshire: 11 work three days per week, none of them works full-time and one of them works one day per week. Perhaps we should also address the loss of 40 working days per week from any similar team, as well as putting in place things that make doctors’ working lives more rewarding and meaningful. If physician associates are part of that then I am fully supportive, so long as they are properly regulated. The Faculty of Physician Associates code of conduct, produced with the GMC, says that physician associates will always work under the supervision of a designated senior medical practitioner and that they must work within the limits of their experience. Let us make sure that these regulations will help make that happen.
Lord Scriven (LD)
My Lords, I have listened to the debate very carefully. My professional experience as a former health service manager over many years is that we have had this debate about people taking on different roles in health and always the same arguments come. Whether it be physiotherapists taking on roles, nurses becoming nurse practitioners or pharmacists coming into this, the same argument always happens: that somehow this dilutes patient care and safety. The answer is that it does not if it is properly regulated, there is proper training and there is proper monitoring of what happens to patients.
I understand that there is some anxiety, but I have to say to the BMA, in particular, that its language in the briefings it has given has driven the bullying and ostracisation of colleagues in hospitals who are valued members of a clinical team. That is the word: “team”. It needs to be led by a senior doctor, normally the consultant, without ostracising people within that team. I gently say to the noble Baroness, Lady—I have forgotten.
Lord Scriven (LD)
The noble Baroness, Lady Bennett of Manor Castle—I remembered the Manor Castle because of Sheffield, but I could not remember the Bennett bit—that, twice during her contribution, she used the term “a second-rate service”. These people do not provide a second-rate service; they provide and augment the team service, to ensure that patient outcomes are as good as they can be.
On the whole, I support the fact that these orders are being laid, although there is one issue that I think needs to be thought through carefully: if the GMC is going to regulate, there is an issue about the way that the distinguishing of the registers is dealt with. I see that as a potential trip-up point if not thought through very carefully; I hope the Minister can give the House some assurance on that.
On the whole, I support the regulations. This is just a continuation of many years of different people in the team taking roles. With the correct regulation and the correct training and supervision, this will improve patient outcomes and service.
NHS: Dementia Commission Report
Lord Scriven Excerpts(1 month, 3 weeks ago)
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Lord Markham (Con)
My noble friend is correct; I did not see reference in my noble friend Lord O’Shaughnessy’s report to music therapy either. I am familiar with some of the principles behind it. My personal experience myself with the elderly dementia patient that I cared for was that bringing my five year-old son along took them out of their position and made them care for that child and forget about their own situation. Those sorts of therapies—and music is similar—have a vital role that we will look into further as part of this plan.
Lord Scriven (LD)
My Lords, the Alzheimer’s Society has a good report out called Dementia: What Every Commissioner Needs to Know, about Alzheimer’s care. What is the Government’s view on ensuring that ICBs across the country have a minimum standard of commissioning levels for people with dementia?
Lord Markham (Con)
We have set out a dementia good care planning guide to exactly those commissioners because, as ever, we need uniformity in these areas. Part of the strength of ICBs is that they have freedom to deliver local services, but we have to make sure that they are always achieving at least the minimum levels that the noble Lord referred to. That is what the guidelines are about, and we are setting monitoring against that to make sure that they are delivering on it.
NHS App: Medical Records
Lord Scriven Excerpts(4 months ago)
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Lord Markham (Con)
In terms of averting it, there are some of the measures I was talking about. For instance, with facial recognition, if anyone else is seen in the picture, it disregards it, so that you cannot have someone else holding it or holding their head in to do it. If the person’s eyes are shut—if someone is trying to do it while you are asleep—it does not work either. Those safeguards are in place, as well as multi-factor authentication, so that if anyone tries to change their details by email or whatever, it comes back to them. We have worked with user groups on this. I will come back to the noble Baroness specifically on the Ministry of Justice conversations, but we are doing a lot in this space.
Lord Scriven (LD)
My Lords, digital transformation of the NHS at pace is being held back by the number of vacancies for digital roles within the NHS, particularly when many people are going over to the private sector for higher pay. What could the Government do to deal with this, particularly regarding the inflexible Agenda for Change?
Lord Markham (Con)
The noble Lord is absolutely correct. Digital resource is well sought after. I was approving something just the other day which gives us more flexibility in that space, because sometimes you have to pay over and above to get people on it. As we all agree, this is vital to the future of what we are trying to do.
Black and Minority Ethnic Babies: Mortality Rates
Lord Scriven Excerpts(5 months ago)
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Lord Markham (Con)
Yes, it absolutely does fit into it. We have increased the number of maternity staff by about 14% since 2010, and the long-term workforce plan is all about making spaces for 1,000 extra students and having many routes into it. Noble Lords have often heard me talk about how my mother got into nursing as an older mum—she got into maternity services. There are apprenticeships and later-life opportunities. You should not only be a graduate; you often know much more about life when you are that bit older, especially if you are a mum.
Lord Scriven (LD)
My Lords, child mortality rates in all high-income countries, apart from this one, are improving. What is it about this country that is causing this, and what evidence do the Government have to show that there is a specific problem here? What measures will be used to tackle this, and by what dates will this be done?
Lord Markham (Con)
I have specifically investigated infant mortality rates. If you look at it, you see the increase is in pre-24-week term cases. Post 24 weeks, the number of cases has remained stable, the data has shown. I have been trying to drill down to understand why it happens within less than 24 weeks. Clearly, more work needs to be done. We are also changing the way this is being measured. We are looking for more indications of whether there are early signs of life, and if there are no early signs of life, that is not recorded as a death. Now there is a lot more investigation to understand those early signs of life, so the change in measurement could be increasing the numbers. I am happy to go into more detail on that.
Stroke Care
Lord Scriven Excerpts(9 months ago)
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Lord Markham (Con)
I thank my noble friend. As we all agree, there are always two steps involved: setting out the guidelines that we believe are best practice and making sure that they are then implemented. ICBs have that responsibility and regional managers look into them. As I think I have mentioned before, each Minister personally takes charge of six or seven ICBs—I will visit a few of them in the next few weeks during Recess—so we can make sure that they are really delivering on the ground.
Lord Scriven (LD)
My Lords, the Getting It Right First Time report has shown that 29 recommendations are needed for strokes and its wider programme has shown what works in the healthcare system to improve care and save lives. What levers do the Government have when integrated care boards do not implement best practice to save lives and improve health in an area?
Lord Markham (Con)
There are a number of things. For want of a better phrase, we have a tier rating for the different trusts and hospitals and they can be put into the equivalent of special measures—that is not the right term, but the noble Lord knows what I am referring to. Ultimately, the NHS and Ministers also have the ability to hire and fire, as we know that leadership is vital in all these areas.
NHS: Performance and Innovation
Lord Scriven Excerpts(10 months, 1 week ago)
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Lord Scriven
That this House takes note of the current performance of the NHS and innovation in the health service.
Lord Scriven (LD)
My Lords, I clearly need to put a different aftershave on tomorrow.
I wanted to have this debate because I feel that the time is right for a discussion to be had in this Parliament that really focuses on the future of the NHS and that asks some fundamental questions that will hopefully stimulate further discussion in senior positions in government, NHS England, the professions in the service and the population. Today I want us to have a discussion based on mature politics, rather than the normal knock-around. I think the Minister will be quite surprised that I, of all people, am saying that. It is fascinating that most of the debate on the NHS and health—when they are discussed in this building, in both Chambers—is predominantly about how to tinker with or improve the existing system. It is very rare that we step back and ask some fundamental questions about the system itself and the outcomes that it achieves.
I could go in depth into the performance of the NHS and the processes and measures that are in place that dictate the behaviour about how people in the NHS then perform and what is seen as important. It could be about the 7 million people waiting for care. It could be about the lack of fast access to some cancer services or the length of time it takes to get an appointment with a GP. It could be about the length of time it takes an ambulance to arrive if you ring 999. It could be about the inability to get good oral health through having access to an NHS dentist. It might be about the real lack of parity of health services between mental health and physical health. I could point out the rate at which community pharmacies are closing and the effect that that has within communities. Again, I could point out the poor access to, and rising wave of problems in, sexual health services. Of course, one cannot discuss the performance of the health service without saying that the crisis in social care has a direct effect on the health of the population.
If I do that, however, the Minister will come back with a ream of figures about what the Government are doing to improve the present system. The Minister will come back with a platitude of figures about what is happening. That is all about the process, but we need to start from the outcomes of what the health service is trying to do. What we are trying to do is to fix the infrastructure of a health service devised in the 1940s for a 21st-century Britain.
Let me give the House an example of how this could change. I work with a country in Africa where people said, “We do not have enough pharmacists”. This is a rural country with three urban centres and a massive rural area the size of Italy. “We do not have enough pharmacists; we need more pharmacists,” they said. However, when you start asking what the purpose is of pharmacy and pharmacists, and what their role is in the healthcare system to improve the outcomes of patients, part of the answer is that it is about the distribution of the correct drugs at the correct time to the correct people, so that they can lead as independent a life as possible. They got to the point of thinking about posing the question slightly differently. The answer was not about more pharmacies; what they did was to innovate, based on a different question. They got drones with compartments for drugs going to a central depository and then flying, docking on solar-panel charges; the compartment for that village opened; somebody in that village had been given a job to distribute to that village; and then the drone went to the next village. It was not extra pharmacists that were required; it was access to drugs that was required. By asking a different question and starting with the outcome, you stop just going absolutely focused on process.
I am sure that, at some point in this debate, the Minister will tell us that new hospitals are being built. I am not going to go into numbers of hospitals, but we never question what a 21st-century hospital is. What are we actually building? Are we building the existing model, which in some way replicates the problem of people not being able to get access to planned elective care, because emergency care pushes it out? I know lots of medical people—doctors, nurses and others—and they all say that the reason why I cannot get my hip replacement or I cannot get my ophthalmic eye problem seen to is that emergency care takes over the theatres. One of the things we have to do, therefore, is to say that hospitals need to be different.
It is the same with primary care. We have to think about what primary care will be needed for the future. I will come on to some of the ideas that I have, but innovation is not just about technology and data. It starts with culture, leadership and thinking. It is really important. The Government will tell us—when I go into some of the things that I am suggesting—“Oh, we already have that with ICBs and ICSs”. No, we do not; what we have is a governance structure. ICBs and ICSs become obsessed with structure and governance, and they are not given the space to innovate.
A key, central issue with the NHS that we need to address as a nation is that in some areas, we might just be doing the wrong things a little bit better. It was telling that, in all the great briefings that we had for this debate—many organisations gave us excellent ones— most of them focused on the acute sector and what was needed to improve it. That is quite clearly a vision of health shared by many people who work in the health service. Therefore, if we start with a different view on performance and the purpose of the NHS, we will start with a very different discussion about what is required to innovate, to improve outcomes and not just to tinker with the present system.
If we start to look at the purpose of the NHS as to reduce health inequalities, it might lead to a different discussion—a different focus on innovation to improve outcomes and reduce health inequalities, not just to keep the system running a bit better than it is. If we say that the purpose of the health service is to help in partnership to increase the number of healthy years lived and to ensure that people retain their independence and dignity, the focus on behaviour, structures and systems will be different. That will lead to the NHS having to think much more about population and community health approaches. It will lead to a step change in what is seen as vital to improve health, so it is not just about drugs, doctors and operations in the present but about a shift in who does what, where and how. I do not suggest that hospitals and operations are not important—of course they are—but they are only part of the jigsaw, and too many people see them as the only part of it.
I will suggest some changes. I am not suggesting that these changes need to be adopted but that we just need to think about a different approach. Some of the innovations that might be required might be the following. Do we have different types of hospital: acute hospitals and non-acute hospitals, tertiary hospitals and planned elective hospitals? There are pros and cons for the existing and alternative models, but the issue is what we actually do so that for those who have a planned operation, the whole system works and innovates to meet their needs and they are not stopped going to their emergency care.
Where are step-down services? What innovation do we have around those, so that when people are in the recuperation phase, services are provided? Should the primary care model exist in its present form? Should we have a different type of approach to primary care, so that people like me, who probably go to my GP once every six, seven or eight years, have a different model from those who have ongoing care needs with comorbidities?
I will go further. Do I have to register with a GP at all? If we are going to unleash the potential of pharmacists, who say that now, with the correct funding and system, they could do away with 30 million GP appointments a year, should I register with a pharmacist? A pharmacist can build services around them, linked to IT, to data, and to my healthcare record. I do not suggest that that would work—there would be problems—but we have to ask some fundamental questions.
What is the role of the people who provide care and health provision for people allied to medicine—the OTs and physiotherapists? Predominantly, it is still an acute service. There are people in the community sector. There has to be a huge shift. If we are looking at outcomes, keeping people in hospital to have their OT or physiotherapy is ridiculous. We have to think about how we do this. With older people, for example, one of the biggest issues when you look holistically is social isolation. Yet the health service, for reasons to do with efficiency, has moved that provision back into somebody’s house rather than thinking more holistically about independence and dignity and what can be done in the community with other partners to provide not just the physical part of healthcare but the well-being in terms of stopping social isolation.
Central to all this is people’s lived experiences and that being central to part of healthcare planning and provision. That is something big. Innovation is not just about the data or the technical stuff but about the people. It is about leadership, both clinical and non-clinical, and the type of training that is required. In the future it will not just be about technical specialists but about a community-based approach which will mean that people will have to be great facilitators and bringers-together of networks to be able to build services around shared outcomes based on real people’s lived experiences. That has a big impact for the forthcoming workforce plan. It has to be a workforce plan for the future, not just on how we are going to fit the gaps that already exist in the service, otherwise we will be on a merry-go-round—so I will be quite interested to know the Government’s thinking on this.
In finishing, I say that this debate has to be about the future. It has to be about data, IT and artificial intelligence, but it also has to be about the culture and leadership, and about a community approach which completely changes just tinkering with the existing system, thinking instead about what is required and what innovation is needed for a future health service provision. I beg to move.
Lord Scriven (LD)
My Lords, I thank everybody who participated in this debate, including the Minister, for approaching this in the spirit of the debate’s framework, which was to concentrate not just on the problems but on some of the innovative solutions that can help to take forward not the health service but the health of the nation.
I will finish with a quote from a GP in south Cumbria, who said:
“I feel frustrated that I am working in a health and care system that increasingly fails to meets the needs of people. It is not fair for people to have to keep returning cyclically without us making a fundamental difference to the root causes of their problem”.
There are three or four things I want to take away from this debate and make sure the Minister really understands. The first is that the centre has to move away from an obsession with governance and actually support people a little more in terms of how to innovate. It needs to give people a little more space to evolve some of the issues.
The other thing is that this is about people, people, people. It is not necessarily about the big bells and whistles. The technology is fine, but if the underlying people problems still exist, no matter what app you get, that system is not solved; it just replicates on a digital platform the real issue that is going on behind it. Also, people’s experiences—I mean not just staff but real people, those we call patients—are really important.
My final tip to the Minister is sometimes to go to areas that do not have good practice. I did that when I was leader of Sheffield City Council. The Minister’s officials will want to go to the areas of good practice, but he should go to some of the areas where take-up or innovation are not great, because he will get a different perspective that will then help support the rollout. With that, I thank everybody who has taken part.
Dementia Palliative Care Teams
Lord Scriven Excerpts(10 months, 1 week ago)
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Lord Markham (Con)
The voluntary sector is a key element of this. On behalf of the department, I thank it for all the work it does. The direction of travel is very much to engage the sector and enlist its support as much as possible. The ICBs do the commissioning, and Derbyshire is a fantastic example of commissioning all the different strands, including the voluntary sector, hospices and palliative care to deal with clinical need. It is an excellent example of how to do it well and one that we need to spread everywhere.
Lord Scriven (LD)
My Lords, this service is patchwork, yet the demand is across the country. What can NHS England do to ensure that the unmet need for palliative and end-of-life care for people with dementia is met?
Lord Markham (Con)
First, we were very upfront about it; part of the Health and Care Act 2022 is that the ICBs commission palliative care. Secondly, it is part of the six major conditions strategy. It is a major cause of death; about 11.4% of all deaths are caused by dementia. It is fundamentally the responsibility of the ICBs but we at the centre are making sure that the ICBs are commissioning in the way they need to.
Pharmacies: Medicines at Home
Lord Scriven Excerpts(11 months, 1 week ago)
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Lord Markham (Con)
The noble Baroness is absolutely correct. It is the patient, or often their proxy or carer, who absolutely should be considered in this. It is the responsibility of the pharmacist to make sure that they are taking that into account. Again, I say very clearly to patients or pharmacists: if patients do not believe that they are getting the right packaging, and they believe that they need blister packs, they should absolutely be speaking to the pharmacist and the pharmacist should be providing that solution.
Lord Scriven (LD)
My Lords, the Minister said that there were an extra 24,000 pharmacists. He will be aware that community pharmacists have complained that primary care networks are poaching them because they can afford to pay them more and community pharmacy is £1 billion short for providing existing services. What are the Government doing to plug that £1 billion gap in order to ensure that there are enough community pharmacists?
Lord Markham (Con)
As I say, I do not recognise those numbers. I do recognise that we are putting £645 million more into this space to fund this, and also that this will drive more people into pharmacies, who will not only go there for an appointment, but, no doubt because they are already there, they will generate other business off the back of it. I think and hope that this will actually reinvigorate the local pharmacy sector to the good of local communities and local people.
Health Education England (Transfer of Functions, Abolition and Transitional Provisions) Regulations 2023
Lord Scriven Excerpts(1 year, 1 month ago)
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Baroness Watkins of Tavistock (CB)
My Lords, I declare my interest as a relatively new non-executive director of NHS England, appointed together with two expert doctors to give clinical input to the board and tackle the issues that have just been discussed. However, I want to put on record that I think Health Education England has been a success and has set up sound processes that have enabled a good estimation of the workforce needed for the next 15 years.
The workforce plan is in draft and is being considered by the Government, but I want to underline the fact that, without sufficient funding, it will not achieve what everybody wants it to achieve. I believe that making it mainstream in NHS England should mean that, working with the ICBs, we have a sound approach for the future. I am aware that the two previous speakers will be able to hold NHS England to account on whether we get it right or not. I felt that I should be here this afternoon to say that I think it will work, but only because of the sound foundation that NHS Education has left behind.
I also want to echo one concern: that we have to calculate social care needs within the workforce development plan, in particular the needs of leaders of teams in social care, who are often nurses or allied health professionals such as physiotherapists. On that note, I will sit down; I wanted to express my current understanding of the situation.
Lord Scriven (LD)
My Lords, I wish to add briefly to the very useful and interesting debate that the noble Baroness, Lady Merron, has stimulated with her amendment. In so doing, I point out my interest as a vice-president of the Local Government Association.
I support the general direction of the merger. I can see why HR functions need to be streamlined together rather than partly devolved and partly in NHS England. The Minister quite rightly pointed out his business background; I have a background in organisational development and public sector reform, not necessarily in the UK but in Africa and south-east Asia. One of the key failures in the public sector when these organisational structures happen, predominantly for cost reduction reasons—it is always said by those leading them that cost reduction is not the reason, but it is important—is that there are no measurements for success in three, five, 10 and 15 years. Without that, you get a structure without understanding how the structure will deliver exactly what is needed.
So, what are the measurements for success in three, five, 10 and 15 years? Without those, everyone can say there is a target, but no one knows what that target, or bull’s-eye, really is. What are the clear measurements within three, five, 10 and 15 years? If they are not there, how do we know what success looks like based on what the merger was about in the first place? That is really important.
The other part of this is that you can have all the training and numbers you like for the workforce, but if the support, conditions and culture are not right, people will leave, as they are doing now in parts of the NHS. In certain specialties, you cannot get a doctor for money, no matter how much you offer. Part of that is about working conditions, culture and support. How does this merger deal not just with numbers and education but more holistically with the culture and support? For example, in many trusts, junior doctors cannot even get a meal in the evening. You can have all the numbers you want in terms of training, but if people decide not to work because of the conditions, how does that help holistically? How do we ensure we have not just the training and numbers but the culture and support within organisations so that people decide to go and work there?
My final question is simple. All noble Lords who have spoken have mentioned social care. As I said, my question is simple: how does this plan link with a plan for the social care workforce? What problems are envisaged and what mitigation has been put in place to ensure, first, that the two plans work in tandem and, eventually, as a long-term aim —I have heard Ministers talk about this—that staff will be able to move across the organisational divide? How will the links be there? What mitigation is being put in against the risks for a social care plan and a healthcare plan? This is important because people who start with a health problem then require social care to make as good and independent a life as possible. It is important that, when the Government start on one plan, they understand the linkage with the other and the mitigations needed. I hope that the Minister can put the mitigations in place.
As I said, in general, I understand the reasons for this but there are serious questions that the Minister needs to answer to ensure the maximum impact from this merger.
Lord Markham (Con)
I thank noble Lords for their contributions to today’s debate. As ever, I will attempt to answer the questions as best I can, and I will come back in writing with the details.
First, on when the workforce plan will be published, forgive me for this answer but I cannot resist it. I looked on the HEE website and it will be delivered “at the right time and in the right place”. I could not resist that one. I think the term I am allowed to use is “shortly”, which is different from “soon”, but I will let noble Lords decide. Seriously, however, there is a very detailed plan. While I acknowledge that there are concerns about delays and this being “Treasury-fied”, at the same time, serious questions have been raised, as we would expect. This is leading to a lot more thinking, which is the right thing to happen, provided we come out with the right answer. I hope noble Lords understand that work is going on to ensure deliverability.
I will try to answer the many questions asked, particularly on what the measures of success will be, as raised by the noble Lord, Lord Scriven. From my point of view—it may be personal—we are publishing the workforce plan and the measure of success will be how well this body performs against that. It will not be down to that body alone; it is part of the newly merged entity. As the noble Lord, Lord Scriven, said, it is about recruitment, training and retention.
A key issue, as I know from being tangentially involved in some of the conversations with unions in the last few weeks, is a real recognition on our part that pay is a core issue, but so are things such as hot meals, rest areas for staff and parking. Some of those issues are important “health factors”, if you will excuse the pun, and we are very alive to them.
Turning to the questions raised by the noble Baroness, Lady Merron, and the noble Lords, Lord Allan and Lord Scriven, as I say, it is about looking at savings across the piece. As noble Lords will know, we are talking about quite a considerable structure. The average trust is run by 300 or 400 admin staff; an ICB has 700 staff; a region has 650 to 700 staff; the NHS itself, at the centre, has 4,000 staff; and the Department of Health and Social Care accounts for another 3,500 to 4,000 staff. I think we would all agree that layer upon layer of management is not good, from not only a cost and efficiency point of view but a management point of view. We all talk about our various backgrounds, and speaking from mine, the fewer layers you have between the so-called management and the front line, the better. That is the wider picture of what we are trying to do here.
Lord Scriven (LD)
I totally agree. I think Tesco, for example, has four levels of management between the customer and the chief executive. But I hope the Minister understands that, regardless of layers—this may not make me popular outside this place—the NHS is one of the most effective health services in western healthcare in terms of management costs. I hope the Minister does not take the populist view that having a go at the managers suddenly makes savings. We have to get the balance right. On comparators, the NHS is significantly well placed in the western world in terms of its cost ratio of managers to patient care. I hope the Minister will accept that.
Lord Markham (Con)
The noble Lord is right: it is about the effectiveness of the layers. I come at this from the view, “How do we make this most effective?” That is the major gain to be won from all this.
The noble Baroness is right to bring up the issue concerning the Secondary Legislation Scrutiny Committee. I have spoken to all the staff in the DHSC about it, and I have given assurances to the House on the importance we attach to it. I am meeting the Leaders of both Houses tomorrow to discuss how we are working to make improvements in this space. Hopefully, we are making progress.
I thank the noble Baroness, Lady Watkins, for her contribution. It is fantastic to have her on the board, given her experience. Several noble Lords asked about the social care element. As we know, the situation is slightly different because most people in the social care space are employed by third-party organisations. There will not be a direct read across, but the Minister will be announcing shortly the next version of People at the Heart of Care, which aims to address a number of issues. It is probably best to wait for that, and we can take it from there.
I have tried to cover as many of the issues raised as possible, and I am quite happy to follow up in writing any I have missed. Reassurance was sought regarding current training budgets, pointing out that, while we want to make savings where possible, we need to know they are being made in the right place. A separate board structure is being set up within the organisation to make sure that such matters are separately scrutinised and not lost within the overall picture, because it is understood how vital that is. These are all elements I will try to cover more completely in a written response.
Lord Scriven (LD)
That is a helpful answer. To be clear, you can have a separate board, but if the budget is not ring-fenced, all that they are scrutinising is a smaller budget. I think the question that was asked—although maybe not specifically—was, will the training budgets be ring-fenced and will the board therefore be looking after a ring-fenced budget?
Lord Markham (Con)
I think that is probably one element I need to come back to the noble Lord on in writing.
As I said, I will try to follow up the questions in detail. I welcome the contributions of various noble Lords and their understanding of what we are trying to do here. I understand the arguments, as an ex-management consultant, regarding centralisation versus decentralisation and how they go in and out of fashion. This is a slightly different case because it is about bringing a core function in house. To me, that is the key change and the key thing we will be seeking to measure. As well as setting out clinical needs, the key role of the NHS at its centre is making sure that it is recruiting, training and retaining talent to meet the workforce plan needs. On that note, I thank noble Lords for their contributions and hope that my follow-up answers any questions that I missed.