NHS and Social Care: Impact of Brexit

Baroness Watkins of Tavistock Excerpts

Thursday 21st July 2016 Lords Chamber

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[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.

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[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.