Health and Care Bill

Baroness Walmsley Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 24th January 2022 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

I am most grateful to the noble Baroness, Lady Barker, for adding some clarification to the point that I was trying to make. I am not for or against any system; all I am saying is that the arrangements have to be in place so that nobody is jeopardised—and indeed, in the event of a patient being transferred from a private facility back into the NHS, that part of the NHS is appropriately recompensed, particularly if the patient comes from a long way away.

[Baroness Walmsley (LD)]

My Lords, the problem to which the noble Lord, Lord Warner, is suggesting a possible solution is the result of long-term underplanning and underfunding of staffing in the NHS, and underfunding also of the capital budgets of hospitals, which sometimes have to choose between mending the roof and buying a piece of equipment that would get patients through the system more effectively and efficiently.

On the comments from my noble friend Lord Rennard on self-management, it is of course not just better care that that produces—it is also very cost effective. I draw noble Lords’ attention to page 3 of the Bill, line 13, where one of the three things to which NHS England has to pay regard about the wider effects of its decisions is

“efficiency and sustainability in relation to the use of resources”.

The resources are much better and more efficiently used if the patient has a decent choice of the equipment and treatment that is most effective for them, and it is often a great deal cheaper.

I also agree with the noble Lord, Lord Lansley, that we need the guidance. We need to see it before Report, and I hope that the Minister will be able to provide that.

[Baroness Wheeler (Lab)]

My Lords, these amendments stress the importance of patient choice in health management, especially of their long-term health conditions, and I welcome and endorse what noble Lords have said on these key issues. The vital importance of patient choice and their right to be able to make informed decisions about their conditions and treatment, and to receive treatment within the 18-week standard waiting time set out in the NHS mandate, was pioneered by Labour and continues to be fully supported by these Benches, as I stressed last week in the group of amendments on the mandate and the NHS constitution.

The noble Lords, Lord Rennard and Lord Lansley, and my noble friend Lord Hunt have spoken about the importance of active self-management, where clinically suitable, for patients with conditions such as diabetes. Access to the latest technologies varies greatly across the country, and the call in Amendment 109 to ensure that the oversight framework for ICSs includes systems for measuring the numbers of diabetes patients accessing diabetes technology would help achieve greater consistency and better use by patients who could benefit from it, particularly in helping to keep them out of hospital or to prevent their conditions deteriorating.

As vice-chair of the Specialised Healthcare Alliance, I know that patients with rare diseases often do not feel sufficiently supported in terms of psychological support, health systems and information, physical and daily living, patient care and support, and sexuality needs. As they are often having to live with their conditions long term, they have considerable potential to be more expert in their conditions than many of the healthcare professionals they come into contact with, many of whom may not be familiar with their disease or condition. With appropriate support, therefore, such patients can manage their less intensive care needs themselves, delivering better health outcomes and reducing demands on the NHS. Efforts to promote the self-care of people with health conditions, as set out in Amendment 226, really have the potential to improve the care of people with rare diseases.

Amendment 72—moved with his usual expertise and clarity by the noble Lord, Lord Warner—reinforces the importance of patient choice and is highly relevant because of the growing and record waiting list that we spoke about last week during the debate on the mandate and constitution. Of course, Labour in the past has used the private sector as part of a comprehensive plan to reduce waiting times, as the noble Lord, Lord Warner, pointed out. He will also know that in reality the role played by private providers, and the costs involved in getting the waiting lists down to the 2010 levels before this Government took office, particularly for elective surgery such as hip and knee replacements, were modest compared with the huge investment in the NHS itself and Labour’s genuine commitment to public service solutions, increased investment, the use of targets and improvements in pathways and other efficiencies. As a result, the private sector relied more heavily on getting business from the NHS on NHS terms, not actually treating private fee-paying patients.

In sharp contrast, we have the complete absence of such a comprehensive or coherent plan from the Government to reduce the now-record waiting lists, as the noble Lord, Lord Warner, set out in moving his amendment. The Secretary of State has acknowledged that waiting lists could grow to 13 million, with the National Audit Office now predicting that the situation could get even worse than it currently is by March 2025. The Secretary of State promised in November to publish how the Government plan to meet the workforce requirements needed to address staff shortages—to which noble Lords have also referred to during the debate—and the record waiting lists, but we still have not had any sight of this.

So far, all we have had instead are last week’s press reports of the huge sums of money the Government want to hand over to the private sector, including disturbing reports of NHS England’s unease at the Secretary of State’s instructions to hand over £270 million to the private sector with no guarantees on numbers of patients to be treated or, indeed, whether any NHS patients will even get treatment. Our shadow Secretary of State, Wes Streeting, has made it clear that an incoming Labour Government would fully expect again to use the private sector to help bring down waiting times for treatment, but as part of a comprehensive plan to build and the support the NHS so that people do not have to go private because waiting lists are at record levels and they are suffering and in pain. People who cannot afford it always have to wait and remain in pain. That is not social justice and it is just not right.

We support the principle in this amendment. If long waits can be prevented, they should be, although there is a serious question about whether the private sector would in any event actually have the capacity to meet the demand that could be generated by the three-month stipulation for treatment in the amendment. We also agree that the Clause 68 regulations need to be published as soon as possible and I look forward to the Minister telling us more about that. By contrast, a far better solution, as Labour has always advocated, would be to invest in the NHS, help the NHS become more effective and efficient and build capacity so there would be far less need for private sector care.

Finally, the amendment’s requirement to ensure that private sector providers have a duty to provide NHS England with annual information on the services funded by the NHS and on patient choice would be a welcome development, for the reasons that the noble Lord, Lord Warner, set out. The more that is known about the use of private providers, the better and more informed the discussion about their role will become. I look forward to the Minister’ response.

--- Later in debate ---

Moved by

[Baroness Walmsley]

83: Clause 20, page 17, line 25, at end insert “and to ensure the availability of sufficient well-trained staff to provide safe staffing levels.”
Member’s explanatory statement
This amendment draws the attention of the integrated care board to the need to ensure sufficient well-trained staff to comply with safe staffing levels.

[Baroness Walmsley (LD)]

My Lords, in moving Amendment 83 in my name, I want to speak to Amendment 86, also in my name, and to support Amendments 146, 170 and 171.

Everybody taking part in these debates, including the Ministers, would acknowledge the central importance of the staff of the NHS and social care, at every level, and their training, well-being and retention. However, it was clear from the evidence on the workforce to the committee and in debates in the House in another place that there is broad concern that planning for the provision of sufficient of the right staff in all areas has not been good enough. Given how long it takes to train a doctor, an allied health professional or a nurse, excellent forward planning is essential. Proposals were made in another place to improve that in the future but, unfortunately, the Government would accept only a mandated review every five years. This group of amendments is this House’s opportunity to try again, and I hope the Minister will be able to help us.

These amendments show that, in the opinion of noble Lords, the planning of health, public health and care staff must be based on an accurate, independently verified understanding of both the current situation and, as well as can be predicted, future need. Because the political responsibility lies with the Secretary of State, this information collection and planning must exist at the very top, as well as at NHS England and the ICS commissioning level. Clause 35 refers only to the workforce needs of health services, but Amendment 170 lays down detail on what the Secretary of State must do to fulfil this responsibility, not just for health but for public health and social care, since they are so interlinked. We look forward to the White Paper and legislation on social care and hope that workforce issues will be well covered in them, but we need to address it now, in this Bill, even though it would have been better to hear the Government’s proposals on social care first. Amendment 146 says what must be done at ICS level. Crucially, both amendments require appropriate consultation. But there is something I would like to add, and that is where my Amendments 83 and 86 come in.

Every hospital trust and primary care setting has done the work to identify and agree the safe staffing levels of each type and seniority of staff in each setting. This is based on an understanding of the local context and of the knowledge and skills needed for patient safety to deliver each treatment, and an assessment of how many patients can safely be looked after by each member of staff. This varies enormously from setting to setting—from a whole team of staff to each patient in operating theatres, to one-to-one in ICUs and premature baby units, and to several patients to one member of staff in less acute areas.

During the pandemic, we have seen these levels necessarily abandoned, with, for example, one ICU nurse being asked to care for two or even three patients at the peak. This has been an unusual crisis situation and services have had to be flexible, moving staff from one department to another, always, I hope, under the supervision of a staff member with the correct speciality. Hospitals have helped each other and ambulances have been diverted when no bed could be found for patients coming into A&E. That has been the advantage of having a National Health Service.

It has been very difficult for staff, and many have quit their jobs. We started the pandemic with tens of thousands of doctor and nurse vacancies, and the BMA has calculated that we currently have a shortfall of 50,000 full-time equivalent doctors—more than the number of unfilled posts. Our doctor-patient ratio is 25 years behind that of similar OECD countries. In the UK, before the pandemic, there was already a shortage of around 50,000 nurses, and still the healthcare system is nowhere near bridging that gap. In December 2020, a report by the Health Foundation, Building the NHS Nursing Workforce in England, said that the Government will need to exceed their target of 50,000 new nurses in England by 2024-25 if they want the NHS to fully recover from the coronavirus pandemic.

In January 2021, a survey by Nursing Times indicated that 80% of nurses feel that patient safety is being compromised due to this severe staff shortage, which is why my amendments focus on safe staffing levels. While there has been a good increase in the number of nursing students starting courses during 2020, this will not alleviate the issue of a lack of qualified nurses now or in the medium term. There are particular shortages among mental health and cancer support nurses. Cancer Research has also told us that one in 10 cancer diagnostic posts in England is vacant, which threatens the Government’s cancer target. There are also considerable shortages in other allied professions.

We have also seen a reduction in the number of in-patient beds in the last 10 years and bed occupancy rates well in excess of the recommended percentage. Even before the pandemic, some hospitals had no available beds at all during the winter period, leading to nearly every winter period being labelled a crisis. All this is because of the perennial failure to train enough staff.

Despite the increased use of technology, health and care continue to be people businesses, but there has not been enough effective planning to provide the workforce needed, not just for normal services but to provide the resilience needed for the winter and for future pandemics. This has partly been due to “leaky bucket” syndrome—the failure to retain staff because of the pressure and, in some cases, pay or pension issues. That must change. Health Education England is now to be incorporated into NHS England, and the Bill and the forthcoming social care legislation are opportunities to start again. We have one and a half million care workers, with high turnover. In order to improve retention, good training and a career path are needed.

I turn, however, to the detail of my amendments. Included in the duties of the new ICBs is, as set out in Clause 20, in new Section 14Z41, a duty to promote education and training. My Amendment 83 adds to that duty that it should train enough of the right staff to reach safe staffing levels in all areas. My Amendment 86 adds to new Section 14Z42, which covers the duty to promote integration, a duty to improve the ability of NHS and care staff to carry out their duties within safe staffing levels.

The latter amendment recognises the risk to staff themselves as well as patients when they are forced to work with fewer than the prescribed safe number of colleagues, or to extend their shift by many hours because there is nobody to take over. It is a risk to their physical and mental health and it certainly does not help the ability of student nurses and doctors to learn from their senior colleagues when they do not have enough time to breathe. It also causes burnout, leading to significant numbers of doctors and nurses considering leaving the profession or reducing their hours. Some 32% of respondents to the BMA’s April 2021 Covid-19 tracker survey said that they were now more likely to take early retirement, while half reported being more likely to reduce their hours.

I believe that safe staffing levels are part of the duty of care that employers owe to their employees in the health service. However, the Nuffield Trust, Health Foundation and King’s Fund have estimated that, by 2030, the gap between supply of and demand for staff employed by NHS providers in England could reach almost 350,000 full-time equivalent posts if nothing is done. Worryingly, that was based on pre-pandemic calculations. Overcoming unsafe staffing levels is an essential measure to ensure patient safety and to boost the well-being, morale and productivity of staff and, therefore, their retention. The Bill is an opportunity for the Government to take sustainable action to alleviate issues relating to workforce supply and demand in England.

The duties proposed in Amendments 146, 170 and 171 would be welcome, and I support them, but they are not enough. I think that safe staffing should be specifically mentioned among the duties of the ICB, and that is where my amendments would put it. I beg to move.

[The Deputy Chairman of Committees (Lord McNicol of West Kilbride) (Lab)]

My Lords, we have two noble Baronesses taking part remotely. I first call the noble Baroness, Lady Brinton.