Health and Care Bill (First sitting)

Chris Skidmore Excerpts

Committee stage
Tuesday 7th September 2021 Public Bill Committees

[Karin Smyth (Bristol South) (Lab)]

Q I appreciate that people working together and perhaps substantiating some of those informal arrangements might, in theory, do some of what you hope. However, the employers remain the institutions that make up the integrated care boards—that is the effect of the Bill. You have started to talk about the process. Could you perhaps talk a bit more about how that is enforced, what that means in practical terms for employers and how employers might behave? I am partly thinking of one of the trusts in my area, which, a number of years ago, set up a wholly owned subsidiary company, with the benefit for them of different terms and conditions for staff as a way of saving money. That was obviously detrimental to the healthcare system generally because you are competing for the same sorts of staff. We made the trust stop doing that because we wanted the staff to be treated the same. My point is: the employers, the terms and conditions, the benefits and the way that they will attract staff remain the same. The Bill does not make the ICB the employer or the way to deliver those terms and conditions or ways of recruitment. I think it is a theory. Can you convince us otherwise and show how in practical terms the Bill solves some of those problems?

Danny Mortimer: It is absolutely the case that the individual organisations in the NHS, social care, charitable organisations and local authorities that make up the partnership as well as the board will remain separate legal entities. We do not see that it is desirable for the NHS to move from having 250 separate employers to having 42 employers. What we have in the NHS is a set of national terms and conditions. My organisation has a particular responsibility on behalf of the Secretary of State to negotiate those with our trade union colleagues. We see that they work well for the NHS and I detect no movement among my membership to move large scale away from those national terms and conditions, which cover the vast majority of staff who work in the statutory NHS.

What we see with ICSs is that organisations are increasingly coming together to address shared challenges. We observe that those challenges are not about pay and conditions but about supply. They are about working together to think about how to promote a specific area for people to come and work in, whether that is Nottinghamshire or West Yorkshire and Harrogate, where there has been some fantastic work in promoting careers in the sector as a whole. We see people coming together to work with directly elected Mayors around the skills agenda. There has been some really fantastic work, for example, in the west midlands, with health and social care organisations coming together with local authorities. We see similar work and engagement with the Mayor of London on the skills agenda that he is taking forward. Again, that is being done by organisations working together. That helps partners—local authorities are engaging with health and social care as a team rather than dozens of separate organisations. It also helps us promote careers that span the whole range of settings that we operate in and speaks to the particular priorities of our colleagues in social care. We see some really fantastic examples of that in various parts of the country.

Finally, we see a real opportunity to take forward the work that I have just talked to Dr Davies about. Systems, as they look at their services and their knowledge of the things that they are providing in their communities to your constituents, can inform the national plans that Navina described in her answer to Dr Davies. We can have a much greater connection between local priorities and some of the decisions that are made nationally about how we invest longer term in education. Of course, the NHS workforce is about 50% degree educated or degree equivalent. So there are significant investments that the Department of Health and Social Care, the Office for Students and the education sector make in our workforce. Being able to root that in what it is that local services need and how they are developed seems to us like a fantastic opportunity, and would help us to avoid the problems that we have got into in the last couple of decades with pressure points in various parts of our workforce.

Dr Navina Evans: I will build on what Danny has just described. You have given some really good examples of how local employers are coming together in systems to address workforce issues. I would add a bit more about how we do it and how we can do it even better going forward. Health Education England has a role in developing careers and attracting young people—all people—into the health and care workforce. We play a really big part in that. First, we have found that doing that locally, at a very local level with the communities and organisations that really understand their local populations, has been a really good thing to do. Some of the examples that Danny gave have built on that and we will move forward on that.

Secondly, we have structures in which people boards, at integrated care system level and definitely at regional level, now bring collections of the different organisations together. We have systems that are starting to think about themselves as anchor systems, which means that they can influence employment, the economy and the success of local communities.

Finally, the population health issue has been something that we have really woken up to, and we are cognisant of the fact that we have to focus on and rebalance the health and wellbeing of the population. Through the pandemic, we have learned a lot more about where we need to target our efforts to reduce inequalities. That can only be done really well through collaboration at a local level. Organisations such as mine need to work closely with our partners in NHSE, with the Department and with other national organisations to make sure that we support those local efforts to be sensitive to the needs of their particular population. It is bringing the national priorities, principles and policy into life at a very local level by making sure that we have the systems and structures in place to deliver what is needed locally. We had already started working on that—the work is well under way—and the Bill will enhance our ability to get on with doing that.

[Chris Skidmore (Kingswood) (Con)]

Q I want to return to the issue of workforce planning, which obviously is integral to both of your organisations. You have discussed the strategic framework you have been working on, and hopefully that will evolve into a workforce strategy, which is addressed in clause 33 of the Bill. I have tabled an amendment to clause 33 which is to make the workforce report annual rather than once every five years. I think that the pandemic has demonstrated the futile nature of trying to produce a report once every five years, when we know that the nature of the workforce could change radically during that period. Would your organisations agree that it would be better for that report to be produced on an annual basis? Clause 33 states that NHS England and Health Education England

“must assist in the preparation…in this section,”

but only

“if requested to do so by the Secretary of State.”

You have talked about locally led decision making and planning. Do you both agree that we need better co-creation? My amendment covers the fact that a plan should be developed and agreed by stakeholders in particular. Would your organisations welcome this amendment, which would result in an annual workforce strategy and require it to be developed by all other healthcare organisations working in this sphere?

Dr Navina Evans: From HEE’s perspective, we will deliver on the duties that Parliament decides that we ought to deliver. We feel that we have the capacity and the capability. We can organise ourselves to deliver whatever is required of us by the Bill. The work that we do is lithe—it is iterative. We do iterative planning, in a meaningful way, at the national and system level, so we will be able to respond and fit in with whatever is required of us by the Bill and Parliament.

Danny Mortimer: Thank you for the question. Absolutely, there is an opportunity for the Bill to define a wider range of stakeholders. The systems at the centre of the Bill—integrated care boards and integrated care partnerships—are central to that, and their perspectives, as we have just talked about with Ms Smyth, in terms of the needs of their population and the services they need to put in place to respond to them, need to be at the centre of the process that Navina and others would lead on behalf of the Secretary of State. That is the first thing. Secondly, there is an opportunity through those systems to broaden our conversation to include social care as well as health. That is really important to us on this day of all days, in terms of the announcements later.

In terms of the regular appraisal, we absolutely believe that five years is absolutely insufficient for the task. We also believe that it cannot just be about process. It has to be about setting out clear requirements and clear specificity about those requirements over different time periods. There is something about the short-term need, and there is also something about five, 10 and 20 years. It needs to be regular. We have proposed two years because it is a huge amount of work and that feels to us to be a minimum in terms of how regular the perspective could be, but it may well lend itself to an annual update, as you have described.

We also see that organisations such as Health Education England and Skills for Care, which operates in the social care sector, absolutely have the capacity and capability to lead this work. Their way of working, similar to the Department’s way of working throughout the preparation of this Bill, is about engaging, convening and trying to bring stakeholders together to get a broad range of perspectives. That is our experience of the long-term process that Navina and her colleagues are leading on behalf of the Department at the moment. The Bill confirming that would confirm ways of working that we are starting to see develop with stakeholders in a really healthy and constructive way.

[Hywel Williams (Arfon) (PC)]

Q Good morning. This Bill is mainly about services in England, apart from the part about the health services safety investigations body and clause 112 on Welsh health bodies requesting help. However, there is significant traffic from Wales to England, and a certain amount in the other direction, to access health and care services. This might impact on services in the north-west of England and along the Welsh border. This is a very broad and quick question: in what ways do you see yourselves and other health bodies in England taking account of the priorities and needs of the Welsh Government and of the Welsh population to access health services in England?

Danny Mortimer: There are important links with Wales, and of course with Scotland as well, in many parts of the country. There are a couple of things to say. The first is that there are undoubtedly things that the English system can learn, and is learning, from our colleagues in Wales, Scotland and Northern Ireland who are taking similar approaches in terms of how they respond to the challenges we face in social care and health. In my own organisation, we represent organisations in Wales and Northern Ireland, and there is a really rich learning that we can do there.

Secondly, in practical terms, there are good lines of communication and liaison between healthcare organisations that operate along the borders that you have described. It will carry on being really important that those lines of communication, that liaison, the financial arrangements and the sharing of care between different teams on various sides of the borders continue, and we see nothing in the Bill that prevents that. If anything, we see opportunities through better co-ordination in England at a system level to be able to help patients who travel across from Wales into England, or patients who travel from Scotland into England. If anything, I think we can improve the planning and liaison through what is in this interesting Bill.

Dr Navina Evans: We already have very strong four-country relationships, particularly in the education and training space, where we make sure that we share standards, that we do planning around the curriculum and the reform of education, that we ensure quality and that we go for improvements in the way in which we support and train our future healthcare workers. In the regulation space, we work very closely with the General Medical Council, the Nursing and Midwifery Council and other bodies, to make sure that that happens. They obviously have four-country oversight, so we already work very closely with them. Also, all our professional bodies, such as the royal colleges, have to represent members from across the whole UK. In that space, there is a lot of good work that we can continue to build on, learn from and share as a result of this Bill.

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[The Chair]

Thank you. Now we will hear from Mr Chris Skidmore.

[Chris Skidmore]

Q I know we have spoken about the need for flexibility in the composition of ICBs and also their related duties. I wanted to ask, though, whether it would be helpful if there were greater clarity in the Bill on the role of universities when it comes to training and education. I would think I am the only person in Parliament who has been both a Health Minister and Universities Minister, and it was very clear to me, when dealing with healthcare education, that there was not the integration around higher education and health in the way ideally we should have set it out. The Bill provides an opportunity to perhaps rectify this.

Also, I wanted to ask for your views on the duties for the ICBs, particularly around research and innovation. It may be a terminology issue, but the duty to promote innovation and to promote research, through the ICBs, is only

“on matters relevant to the health service”

or

“in the provision of health services”.

It does not cover the care system. I would have thought that when we look at the very definition of an integrated care board, it should actually be promoting research and also innovation when it comes to the care system, as well as health services. I would greatly appreciate your thoughts on that.

Amanda Pritchard: It is a very good reflection on the importance of education as one of the key partners that would absolutely come round the table. I think that is where the ICS structure really helps us as well, because it allows that broader partnership construct, including education and local authorities. I would say—again, from some of the visits I have done recently—that people are really clear about the importance of things such as housing as part of the partnership, as colleagues would expect. Lots of people with different perspectives and different important roles in the system absolutely need to come together around that broader ICS structure, I think, to really give us the maximum benefit from the legislation that is proposed.

To pick up specifically on education, you are right to say that there are two parts to it. Clearly, there is a role for education providers, whether that is schools, universities or other providers. Part of what we have written into the expectation of ICSs in this core role, which is about contributing to the broader economic and social inequalities agenda within their own area, speaks directly to that. That is as much about education, training and employment within health and care as it is, of course, about the wider economy. The NHS, as an anchor institution in many parts of the country, can be an important player in that as well; so it is very clearly our expectation that education will be a key partner in all those different ways.

On research and innovation, as you have rightly noted, there is again a carry-over from the CCG responsibilities, which carry over into integrated care. We have made it clear in guidance that we see this as a really critical opportunity. Certainly, that is not and should not be limited to health. However, again, we have seen during the pandemic in the last 18 months that the power of bench-to-bedside translational research could not have been clearer, as well as the opportunities now to write in, right from the start—certainly through what we have been doing on guidance—the expectation that that research would be strongly supported and encouraged by integrated care systems as they go forward. Again, that is absolutely with the grain of what the health service wants to do and intends to do. Mark, did you want to add to that?

Mark Cubbon: Just two key points. With universities, we would expect them to be heavily engaged at place level. We have recently published some guidance with the LGA, which considered how we get place-based activities and partnerships so that we have places thriving—the guidance is called “Thriving places”. We also talk about the benefits of the university sector being involved with place-based arrangements, to do all the things that Amanda just set out.

Therefore, we certainly expect that local arrangements and local dialogue, co-ordination and planning around education for local communities can help with recruitment and the workforce contribution that it can make, but also for the betterment of the local community itself.

We would also expect, probably at partnership level, some university input, whether from an academic health science network or indeed colleagues at NIHR. We have recently been doing sessions with NIHR to talk about how to ensure that our clear ambition for this translational research and this health and care research can really be brought to the fore. It is a key pillar of activity that has seen us through some really difficult times during the pandemic and one that will also be essential as part of our recovery.

[The Chair]

Thank you. We now move to the shadow Minister, Mr Justin Madders, and Mr Alex Norris.

Health and Care Bill (Second sitting)

Chris Skidmore Excerpts

Committee stage
Tuesday 7th September 2021 Public Bill Committees

[Edward Timpson (Eddisbury) (Con)]

Q I want to build on that point about permissiveness and take it a step further in terms of the specification in the Bill around ICBs and ICPs—the boards and partnerships. A lot of us on the Committee have been requested to look carefully at individual parts of the healthcare system. That does have a generality to it, covering mental health, children, palliative care and so on, and their representation is very clear within partnerships and boards. Based on your views around permissiveness and flexibility and the different paces ICSs are currently at, how do you see this? How do we reassure people that their views and the particular parts of the health system they represent will get a fair hearing and that the accountability structures will be in place to make sure they are able to come back if they feel they are not being addressed properly?

Matthew Taylor: That is an important point. Let me be completely open about the conversation within the confederation about this issue, for example. We have a mental health network representing mental health providers. Their preference would be to specify the need to have a mental health leader on the board. We as a confederation recognise that view and represented it, but that is not our view overall. Our view is that, partly because configurations differ from place to place—in some places, mental healthcare and community are together, for example—but for a variety of reasons, we would not want to specify further the membership of those boards. Again, that is to maximise local flexibility.

If people feel their voice is not being heard, then that is something they are going to say. We will have to see how this system evolves, but let us start with—going back to a word used earlier—the permissive regime and see how that goes, because after all it is in the interests of everybody in the local health system that they hear the voices they need to hear.

Saffron Cordery: I agree. This is a thorny issue but I suppose it is one of either, depending on how you look at it, the opportunities or the casualties of creating another level of governance in a local system. When you are thinking about putting collaboration on a statutory footing, you have to surround it with some kind of governance to ensure the effective operation of that body.

It is a tricky issue. You cannot have an integrated care board—the board that will govern how funding flows through and how priorities are agreed, decided and implemented—that is so enormous that it becomes unworkable, but there has to be a clear balance between making sure it is not only the big and the powerful who are represented there, but also all the rights and appropriate interests. There are a number of positions specified in the ICB board arrangements, and it will be interesting and important to see how different ICSs use those roles, particularly the non-executive or wider partnership roles that are specified, in order to have a broad range of voices around the table.

It is worth remembering that many other organisations and structures will be taking part in the ICS arrangements. You will have things like provider collaboratives, which are not in the Bill but feature heavily in the guidance that comes from NHS England and NHS Improvement, which are precisely about organisations working together to deliver on local priorities. Many of those are led by mental health organisations focusing on what they need to deliver.

There are other structures within these arrangements, but no one would say it is ideal. It is not the most ideal solution, but it is very difficult to get to a final configuration that is both workable in terms of numbers and reflects the multiplicity of voices in a locality. It is important to have the right engagement at every single level and the right channels feeding up information and priorities, and to understand what is really important in a system.

Matthew Taylor: Today the Government have been talking about the importance of integration in the context of its announcement on health and social care. One of the big questions is going to be about the powers that are devolved within systems to places, and I think it will be at the place level that we will see service integration. The evolution of place level forms of accountability is an important part of that, and again a reason why it is really important to allow these structures to evolve locally. I suspect that in some areas more power will be held at the system level and less at the place level. In other places, it will be the reverse, with most of the action taking place at place level. That reflects the nature of places, the legacy of those places and the relationships that have built up.

[Chris Skidmore (Kingswood) (Con)]

Q I wanted to turn to workforce planning and your views on clause 33. The NHS Confederation, in its written evidence, has suggested that the five-year period for a strategic review on workforce planning is too long. That mirrors my amendment, which has a crack at this. I have suggested an annual review. It was suggested this morning that two years might be the right time length. I see that the NHS Confederation has suggested three years. I want to get your organisations’ views on what a strategic review should look like, but also on the format and how a strategic review should be undertaken so that it actually works as an act of co-creation, rather than being directed centrally by the Secretary of State on to Health Education England.

Matthew Taylor: My area of expertise before coming to the NHS Confederation was work and the future of work, on which I advised the Government, and one of the things I know from that work is how quickly the world of work is changing. It is impacted by a whole variety of things—not least, of course, substantial technological change. In a world where work is evolving very quickly and population needs are evolving, five years is simply far too long. If it were one year, we would be happy. We have fastened on to two years. That would be the minimum that we would want as a gap between assessments of workforce need.

It is also—to emphasise the point that I think you are making—important that this review gathers evidence from a whole variety of bodies, because an enormous amount of extremely good work is taking place around work. Predictions of workforce need are imprecise, so hearing from a variety of voices is important. This should be an independent process, in which independent expertise is brought to bear; there should be wide consultation with those who think about these issues; and a two-year plan would, I think, be an improvement on what is in the Bill.

Saffron Cordery: We also support this amendment and the work that has been done by the confederation and others on this. There is one other element that I would add to this that supports this perspective. It has been really hard, across NHS workforce planning, to light upon one version of the truth, in terms of workforce numbers. Anything that starts to move towards a collective perspective on workforce needs and workforce planning will be absolutely critical.

Getting an agreed perspective on how we create that figure will be fundamental. In my time working across the health service, there have been many different perspectives on workforce—on the gaps, the numbers who are in roles, and what those roles need to be. It is important to have lots of views, but I think this is also important. Although, as Matthew says, it is not a precise science, we need to light upon a version that is independently agreed, but that we all sign up to as the numbers we are working to.

[Karin Smyth]

Q If I may, I will return to the permissiveness and place conversation. I agree with the Bill’s direction of travel around place. I do not like the word “permissiveness”, because we have essentially a local cartel of healthcare providers deciding on resources and their allocation, and that locks out local communities. I am a bit suspicious of the NHS being given permission to do as it sees fit. That is why I put forward the example about ear wax removal—because that matters to local people, as we all know; that is what some of these things come down to.

The Bill falls apart because of the governance arrangements and the accountability, which does not follow the logic of place-based commissioning. My solution for the Government, should they wish to take it, is something around a good governance commission, based on the previous appointments commission-type process. It would bring in skilled people, with clear role descriptions, clear skills and a degree of independence. It would have the trust of local people, and would bring these very powerful chief executives together with local leaders to explain why, in Bristol, you cannot have ear wax removal, or why you are closing certain provision and opening it in Derbyshire or wherever. Have you had an opportunity to look at my proposal for a good governance commission and locally accountable chairs—perhaps elected, or appointed? What do you think of that as a solution that would bring power and accountability closer to local people?

Saffron Cordery: The issue of accountability is absolutely fundamental. One of the things we have not talked about much in this sitting, and which is not talked about that much, is the presence of two bodies in the system. We have the ICB, but also this partnership body that brings together a number of wider partners—particularly local government—with democratic accountability, which I think is really important.

I am wary of adding too much into the structures in the Bill. I understand your perspective on permissiveness, and we need to make sure that there are checks and balances across the whole system, but I would be wary of adding in another structure alongside everything we have. One of the features of this legislation, as I have said throughout the process—we have met the Department of Health and Social Care and talked to their Bill team, who have been very open and helpful—is that it does not really streamline in the way that it thinks it might. It adds to existing structures and processes, rather than starting from a clean sheet of paper and building something that might be deemed to be a good enough model; we will never get to the perfect model.

Right now, what we do not need is a root-and-branch dismantling of NHS structures and something wholly new put in their place, but I think there has been a missed opportunity to look at where we could streamline more. On that basis, I think it is important not to add more in, and it is fundamentally important that we look at the different roles and structures that already exist. From a trust provider perspective, working both at place and within provider collaboratives, and looking at the governance of unitary boards with non-executives and in some places also with governors and members, we see that there is that element of engagement with the community that you perhaps do not see in other places. I do not think it speaks entirely to your cartel point, but it is a step along the way that is well established and well used in many places.

This is a thorny and tricky issue. Using existing structures of accountability will be really important, as well as using the new ones, but I would not want to see anything new added in there.

Matthew Taylor: I largely agree with that, but another point is that if there is a broad policy thrust in this legislation, it is away from a medical model of health towards one that focuses more on social determinants. In the best partnerships—we talk often about West Yorkshire and Harrogate, for example—there is an incredibly strong relationship between health service leaders and local authority leaders. That will be a critical factor in the success of the system. When I look at the best practice emerging in the integrated care systems on issues such as prevention and population health, I see leaders starting to talk about issues such as housing, employment and public space, recognising their importance to health. In one way, that is a progressive move, and one that will probably lead to a louder voice for a variety of local interests, if we understand health much more in these socially determined terms, rather than simply through the medical model.

We had a big announcement today about social care reform, and there is a set of issues that are not in this Bill—issues around health and social care integration, how it will work and how accountability will work. It remains to be seen how the Government address that question.

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[The Chair]

Actually, in view of the time, I am going to ask you not to, Karin. I am sorry, but if we are going to hear from Professor Rae and give Chris Skidmore a chance, we had better just move on.

Professor Maggie Rae: Again, it is good that you have asked for some specifics and related this to governance, because it is very important that we understand how the legislation will be implemented and that the governance is right.

The concerns that members of the faculty would have are quite broad based. While people might be genuinely pleased that we are moving away from a market economy on health, some are very concerned about opening the door to further privatisation. I want to give you some detail on specific public issues on which you said you would like more information. The legislation includes some public health hooks that will make it easier for us to ensure that we have good public health, but I question whether they are explicit enough.

The issue of taking advice on the needs of your population is a fundamental skill of public health. Whether nationally, regionally or locally, the professional job of directors of public health is to assess the needs of the population and provide organisations with the evidence about what will make the biggest difference—cost-effectively, of course. The idea of “taking advice” is a little vague, but strengthening the need for that advice to come from the statutorily appointed directors of public health—the regional directors of public health have been trained to do that and put the needs of population first—might give some strength to the Bill.

In my day job I do a lot of ICS development for the organisation I work for so I have experience of working with ICSs, and many current ICS leaders—I know there has to be an appointment process—are passionate about health inequalities and public health. We have to make sure, as we said earlier, that we have something substantive that guarantees that public health is not down to individuals and personalities, and that we have a framework. We cannot expect Cornwall to be the same as Newcastle, but we cannot have the population suffering from unwarranted variation. If I had a bit more confidence that the role of directors of public health—and the regional directors of public health—would be instrumental in the legislation, the guidance and the assurance process, I would be able to give you more guarantees that things will be better in the future. At the moment, it is a little vague.

[Chris Skidmore]

Q This is a question to Professor Rae about research. I am sure you will agree that research is vital when it comes to demonstrating the changing nature of health care inequalities and potential solutions. Clause 19 places a duty on ICBs to promote research. Is that enough, or would you agree with new clause 9, which I have tabled, which would place a duty on the Secretary of State to promote research? You can promote research, but there is still a need to protect the budget, especially of the National Institute for Health Research. Should that be ring-fenced, so that integrated care boards have the opportunity to finance research, let alone promote it?

Professor Maggie Rae: Again, that is an excellent question. I strive for excellence in our country in relation to all matters covered by the Bill. It is with great sadness that I see that health outcomes have plummeted since the start of my career. Early in my career we had the best health outcomes for cancer in the whole of Europe. I am sorry to say that that is not the case now, and ensuring that the scientific underpinning of this is seen as essential will make us more leading edge.

There are many examples in the covid pandemic in which we have been leading the world, and that is certainly true of the vaccination programme. I heard in a meeting this morning about some amazing research that is just about to start.

There are lots of areas of cancer where we have not progressed in the last five years. I could name the different cancers; we do not have time to go into them. If this research was going to test people’s blood early to get earlier diagnosis, as Councillor Jamieson said, it does not all have to be high-tech, high-cost NHS services. Lots of interventions are low cost. You will not find anything more cost-effective than getting people to give up smoking. That is a classic low-cost intervention. We want our country to be leading, and we want to put everything behind these new organisations and ensure that there is that scientific underpinning and that we do not fall behind other countries. I tend to side with your view that we may need to strengthen that.

The problem with this sort of legislation is that you want to be very enabling, but then you are very dependent on what the biggest problem is in the NHS today. Many of these organisations are trying to balance the books. We have tried to say that it is not all about targets. We can hit the targets and miss the point. The thing is, we are not hitting the targets at the moment either. Thank you for speaking up about the scientific underpinning. I would like us to remain where we are, and do better on science.

Health and Care Bill (Third sitting)

Chris Skidmore Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[The Chair]

Could you speak up a little bit, please? We are finding it quite difficult to hear you.

Pat Cullen: That is not normal, mind you, for a woman from Northern Ireland! I will try again. Principally, our response to the Bill is that the accountability issues do not go far enough in the Bill. We are asking for the Secretary of State for Health and Social Care to not only clearly have full accountability and responsibility for the assessment of workforce planning, but ensure accountability for the delivery of the workforce. It is not just about the assessment. We are all clear about and know about—it has been played out well—the shortages of nursing staff. We had 40,000 vacancies heading into the pandemic. We make up 26% of the workforce. Everywhere you see a patient, you see a nurse, and we need nurses. That is the only way to provide the best care for our patients. We say that the legislator at the highest level must have that accountability and responsibility for the assessment and the delivery of the workforce shortages in nursing.

Professor Helen Stokes-Lampard: The Academy of Medical Royal Colleges has worked very closely with the Government on the development of the Bill, and we have been very grateful for the opportunity to collaborate so far. We have been largely supportive of the direction of travel, but the workforce, in clause 33 particularly, is the one area where we probably still have the greatest concern. We feel that it needs to go further. That builds on exactly what Pat has said. Along with other organisations such as the RCN, we have co-signed an amendment that goes further on that.

We feel that workforce planning needs to be very transparent and collaborative across multiple organisations and agencies, but ultimately owned by the Secretary of State for Health and Social Care. It needs to take on board both the projected supply of workforce already in the pipeline and projected demand. We anticipate that the line representing workforce supply going upwards, and the line representing the demand for need and care climbing even more steeply. There is a gap between them that, at the moment, we cannot quantify. It needs to be quantified and made transparent. Even if the state does not feel it can fund for that gap, we should not be afraid of knowledge. Without knowledge, we run into the risk of repeating historical cycles of boom and bust when it comes to workforce planning. That would be our big plea to you: try to strengthen that, and please do not fear knowledge—it will help us in the end.

Professor Martin Marshall: The Royal College of General Practitioners, as members of the Academy, are completely in line with Helen’s position. There is a marked workforce crisis relating to general practitioners and other health professionals who work in general practice. Without an adequate workforce, it will be very difficult to deliver any of the ambitions of the Bill, so we are absolutely in favour of a much stronger emphasis on workforce. I think workforce planning is an oxymoron and has been for many years in the NHS. This is an opportunity to do something about it.

[Chris Skidmore (Kingswood) (Con)]

Q I have two questions. On clause 33, which we have just spoken about, what would be the best compromise when it comes to planning for a workforce strategy? The Bill suggests five years, and that the Secretary of State should direct Health Education England and NHS England to produce this report. Would you suggest a more frequent process? If so, how frequent should it be? What organisations should be involved with workforce planning, and how would you see that operating?

Professor Helen Stokes-Lampard: We have thought about this seriously—what would be a sensible interval? Having discussed this extensively with colleagues right across the health and care landscape, we have come to the conclusion that two-yearly feels about right. Annually just feels too intense, and it would be too labour-intensive to get meaningful data out in that period; you would run the risk of fatigue in the system. If we go much longer than two years, we run the risk of fundamental change coming into the system—another pandemic or some other national thing happening that needs to be factored in, and of which we need to be made aware. We have come down on two years, and that is the proposal that we put forward.

Every time, the work needs to look five, 10 and 20 years ahead. We need that longer-term projection. It takes so long to train doctors—that is the agency that I represent—from their entry to medical school to consultant independent practice that you need to have that time lag built into the system. That way, you can look at the totality of the workforce and ensure that you have the right interim solutions for the needs of the population.

[Chris Skidmore]

Q Do the other organisations agree with that assessment?

Pat Cullen: Yes, we would certainly agree. We believe that annual plans are too short-term for the reasons that Helen has laid out—training nurses takes three years, and when you think about the added training for clinical specialist nurses and other advanced nurses in practice, it absolutely needs to be at least two years.

Professor Martin Marshall: We agree that two years is the right interval. I think the request of HEE to produce a high-level framework is a good start—that is correct—but it is just a start, and a high-level framework does not help workforce planning on the ground. It is right that most workforce planning should happen at a local level, but some elements need to be managed nationally. Basically, this is such an important issue for the NHS that it needs to be absolutely top priority in the Bill.

Professor Helen Stokes-Lampard: I am conscious that I did not answer the second part of your question about who should be involved. We propose that this be led by Health Education England, but it has to be done in collaboration with NHS England. We cannot look at the needs of the population without involving them. There are other bodies, too. For doctors in particular, we would argue that the Medical Schools Council and the GMC have to be involved. I am sure Pat will have similar views.

In terms of population needs, we need to look at the Office for Budget Responsibility and use the resources of the Office for National Statistics. We need to go widely on this; it is not about saying, “That is one person’s problem to sort, and then the Secretary of State signs it off.” This is a truly collaborative effort, and we need to legislate for and enable collaboration in the greatest possible sense.

[Chris Skidmore]

Q On clause 19 and the duties on the ICBs and ICSs, particularly, in your case, around education, training and research, do you have any thoughts about who might be able to help those ICCs with their duties, and about the role of universities, which are not mentioned in the Bill? How can we integrate not just health and social care, which are the focus of the Bill, but education and training, and what needs to take place for that integration to happen?

Professor Martin Marshall: Universities have an enormous amount to offer. If we look at the way that universities have operated in academic health science networks in the current structures, in many parts they have played a really significant role. I absolutely think that ICSs give us an opportunity to bring universities into the debate.

Education is particularly important here. If the Bill is to achieve its potential of better population health, there are some massive training leads for all the workforce, and universities clearly need to be involved in that process.

Professor Helen Stokes-Lampard: To supplement what Martin has said, we have not criticised what the Bill says at the moment. For us, this is where the Bill is an enabler, and we hope it is a greater enabler that what we have currently. In that sense, the logical thing to do next is greater collaboration. The challenge with legislation is that although it can remove barriers and enable, it does not actually change culture. We need to engage with the individuals who are establishing this and ensure that the frontline educators and clinicians are on board with it to make it a reality.

Clearly, I support what Martin said about the vital need for education right across the piece. I think you will find that the universities are very much up for that and keen. It has been difficult to expand training places across nursing and medicine in short order, but it is something the universities are really stepping up to do. I think we would all argue that we want to go further and faster to deliver the best possible care for the public.

[The Chair]

Thank you very much. We have about 10 minutes, and three people have indicated that they want to ask questions, so if we could direct our questions to one person and keep questions and answers brief, that would be very helpful, because I would like to include everybody.

Health and Care Bill (Fourth sitting)

Chris Skidmore Excerpts

Committee stage
Thursday 9th September 2021 Public Bill Committees

[Dr James Davies (Vale of Clwyd) (Con)]

Q Nigel Edwards, you mentioned the word “reconfiguration” earlier. In an ideal situation, from your point of view, how would you see a reconfiguration decision being reached, and how do you balance that with the need and expectation for ministerial accountability?

Nigel Edwards: The current system dates back to Andrew Lansley, who set up four tests. Do not ask me what they are. I can look them up, but I cannot remember them. However, they were good. They involved local people and clinical support. You had to make an evidence-based case. Then there was a process that involves local stakeholders, and then there was the opportunity for review by the Secretary of State and referral by local authorities and the independent reconfiguration panel, which has been a remarkably longstanding innovation, given the way that NHS organisations are formed and then abolished. It has done, I think, a very good job.

The current system seems to me to work quite well. The Secretary of State still has a say, particularly around controversial decisions, but they do not get sucked into every small reconfiguration and change. You also do not have a point where there is an opportunity for local participants to say, “I’m not going to contribute to this conversation any more. I’m going straight to the top,” and undermine people working together locally. I am of the view that the current system works quite well. I think we said to the previous Secretary of State, “You need to be really careful what you wish for. You may think that your intervention is going to help to move things along and improve innovation. It’s quite likely, from both previous experience and experience in other similar types of systems, to have the opposite effect.”

Richard Murray: I would not disagree with anything that Nigel said. Also, the clauses in the Bill as they stand at the moment are really, really unhelpful. There may be things you could do to make reconfiguration easier, but I think they would be working around the margins of what Nigel said. It would not be wholescale intervention without limit by Ministers in local decisions—that would mean any change, of any service, could go up to the Secretary of State. Also, if you need to make an emergency move for an operational reason, you would need to write to the Secretary of State in advance—you kind of think the clue is in the fact that it is an operational crisis. I think that the legislation as drafted would not give Ministers what they want, so I really think it is not helpful at all.

Nick Timmins: Can I just add to that? I think it is really dangerous for both Ministers and the NHS. Not many people know about the Independent Reconfiguration Panel. It has worked very well. It has dealt with about 80 controversial cases. It quite often suggests some amendment, and the Secretary of State does not have to take its advice, but the Secretary of State almost invariably does take its advice. I think that if we end up with lots and lots of reconfigurations hitting Ministers’ desks, Ministers will come to regret that. If you listen to the views of previous Secretaries of State, they almost always say, “It’s ludicrous we ended up having to make a decision about what was going to happen”—in Nether Wallop or wherever—which was the case before the Independent Reconfiguration Panel was around.

[Chris Skidmore (Kingswood) (Con)]

Q I want to touch on the King’s Fund’s comments in its own white paper in which it welcomed the Bill’s removal of the “cumbersome competition rules” that were introduced in the 2012 Act; and to discuss some of the consequences of competition and why it is welcome that we remove that; and to ask this question. Are there are any unintended consequences from also introducing the duty on the triple aim in commissioning decisions?

Richard Murray: There are a couple of things around competition. Probably the most obvious one is that it never really worked. A lot of care, particularly urgent or emergency care, is not an area for choice in the first place, so you are already dealing with a fairly specific part of the health service and drawing an awful lot of attention into that one element of the service when a lot of the interest is in care for people with long-term conditions and how you stop overuse of A&E and emergency services. There are lots of examples of things, particularly uncertainty around competitive procurement. Commissioners were anxious about where they stood in law so they used, and probably overused, competitive procurement.

I know from speaking to some commissioners that they sometimes felt slightly powerless to influence the provider side so they would put it out to procurement instead. There was very little sign that all the effort and bureaucracy that went into that really did any good at all. Let us step away from that and enable more co-operative working, to try to get the kind of change that we need for long-term conditions, for the real health conditions that this country faces. I should say that a lot of the academic evidence has found no benefits of competition, so not only was it not a helpful thing, it just did not seem to work—probably reflecting the fact that we have such shortages in this country. Competition works only when there is a meaningful choice.

On the triple aim, you would not want the system to get tied up in a new round of bureaucracy, form filling and ticking boxes, to show that it has duly considered the triple aim. I think it is also important to make sure you do not lose the issue of inequalities from the triple aim. I would not want to exaggerate: does legislating a grand vision make people do things differently on the ground? I think it is helpful to remind NHS providers and others that absolutely they should be thinking about the quality of care; absolutely they should be thinking about value for money and making sure they are efficient. But they also have a duty to the health of the wider population. You can then, through that triple aim, bring the different parties in this system closer together, and I think that for some non-executive directors and for governors, it is quite helpful to know that they are all working in the same direction. So I would not exaggerate the kind of change it would bring, but I think it is a move in the right direction.

Nigel Edwards: Can we just nuance the competition point? Actually, there were two elements to the competition regime. One was the very formal going out to tender and big, bureaucratic procurements—often resulting in the reappointment of the previous provider at significant expense. But the other component was patient choice—for diagnostics, for maternity and for elective surgery. I think that dynamic has benefits. One of the slightly worrying things in some of the plans produced by the ICSs’ predecessors—the STPs or strategic transformation partnerships—was a wish to “repatriate” work, as they called it, which meant to bring work back from providers outside their patch into their own. That was not necessarily a good thing; patients should have the opportunity to have a choice of provider and, particularly in the case of specialised services, one would be concerned about people saying, “Let’s grow our own services locally,” rather than, “Let’s use centres of excellence.”

The maintenance of patient choice, and ensuring that ICSs do not act to limit patient choice, particularly for those patients living on their margins, is quite an important dynamic; almost all ICSs have borders with someone else, and patients naturally flow across them. People want to be able to make choices, because they have an existing relationship with a provider or because they have a relative who lives nearby and could care for them while they are there. There is international evidence that that dynamic has a beneficial effect on providers’ behaviour.

[The Chair]

I think we had better move on. Dr Whitford?

--- Later in debate ---

[Dr Davies]

Q Gerry, do you have any comments to add?

Gerry Nosowska: Yes, please. I completely agree with Stephen on the principles behind discharge to assess, and we have good experience within social work of it working when there is clear shared responsibility and the person is kept at the centre of it. We also have evidence from our members of the potential for rapid discharge to assess, without real advocacy and potentially without the involvement of social work, to lead to some undermining of people’s rights around potentially being placed in a more restrictive environment and potentially struggling to have access to their family. It is partly about resourcing, but it is also about the ethos of human rights and people’s right to be heard and to have choice, and then having the practical backing to follow things up well.

I think that people with experience of social care and health want to have a really clear and transparent process. For that to happen well, we still need some safeguards around that transition. It is a complex moment in people’s lives, and I would want to see social work involvement in the guidance around that. But we also need to be thinking, if we want people to have more of their care closer to home, about how we rebalance resources—this relates to the previous question—by making sure that there are incentives for the resource to be put into community and local support and not just into the most urgent matters.

Stephen Chandler: Could I come back in? One thing that I omitted—it was remiss of me—was that we also need to never forget the importance of the support for carers, particularly around hospital discharge. All too often we are focusing on the individual in the hospital bed and the need to get them out, but we also need to ensure that we are not overlooking or not giving due regard to the role of the carer in that. If I could ask you to do anything, it would be this. Can you just ensure that the emphasis on the role of carers and how all of this is going to help the role of carers is brought through? Without carers, the health and care system would disintegrate rapidly.

[Chris Skidmore]

Q What confidence do you have in the discharge to assess model? Obviously, there have been pilots since 2016, but a lot of this was accelerated through the pandemic. That may be a good thing, but it might also be a bad thing, in that we have now to look at data in a very short timeframe. I served on the Health Committee over a decade ago, and during those discussions around tables like this, we used to talk about the Liverpool care pathway and how that was a good model to be following, until it unwound spectacularly and its local delivery was not as was thought in Committees like this. I wanted to ask what your view is on discharge to assess. You have mentioned carers and ensuring that we take into account the need for carers to be able to cope with any rapid discharges. Are there any other concerns that you might have about the model that should be taken into account?

Stephen Chandler: You are right: discharge to assess and, indeed, the “Home First” model of three pathways is not new. It has been around and used up and down the country for a decade or so now, so there are some well established services that you can draw some really good data from. Before I was in Oxfordshire, I was in Somerset, and we did a lot of work in the Somerset system to develop “Home First”, because our delays were really poor. We saw significant improvement in the outcomes for patients in the first instance. We then saw significant improvements in the flow from the acute hospitals, and I would say we also saw some significant benefits to the local authority in relation to the commitment it had to individuals on an ongoing basis.

I have been out of that system for over two years, but the work that it has done since then to take that even further is phenomenal, and I would encourage you to talk to some of the health and social care professionals in that system. One of the hallmarks of the system is that it does not rely solely on health and social care professionals. It has brought what it refers to as community agents and village agents into the hospital to help with discharge. It has got the voluntary sector as an equal partner. It is helping the individuals beyond the health and care needs that they have in leaving hospital.

I personally believe that discharge to assess is a robust and positive model, and I am hearing nothing to the contrary from director colleagues. What I am hearing from director colleagues, though, is real anxiety about conclusions that might be being drawn from the very point you made, which is that we have tried to evaluate discharge to assess in a very short period of time, and at a time when demand and pressure on the service has been at its most acute. Remember that it is not just the physical demand on those services that we have been experiencing; we have been working on an assumption that there is likely, at any point, to be an immediate surge in the demand for acute services, so we have been working to try to ensure that there is always capacity behind us should a further wave—either a local or a national wave—occur. We have been, up and down the country, operating systems at a pace that I have never seen before, as a result of covid. I would be cautious about drawing out any strong opinions around discharge to assess from an evaluation that was done during that covid period. For me, it is the only model that really helps people leave hospital in a timely manner.

I do not know about any of you, but as I get older and hospital admission becomes more likely, I want that hospital admission to deal with the acute need that requires it, but I want to go back home as quickly as I possibly can and to be able to continue to regain the independence I had. I do not want to become reliant on the local authority for all my support, which is why that reablement support at discharge is so critical.

Gerry probably wants to add to this, but the multidisciplinary approach that has a social worker and the local authority at its heart, building upon not just the professional expertise we bring but the relationships with our communities, our voluntary sector and our social care providers, is critical to that success.

[Chris Skidmore]

Thank you.

[The Chair]

Do you want to add anything, Ms Nosowska?

Gerry Nosowska: Yes, please. The issue with getting out of hospital is not about getting out of hospital; it is about getting your life back and getting back to your normal life. We know that reablement can be a really important part of that. The persistence, co-ordination and attention to the impact of a transition from hospital to home is something that social workers can really help with, and I do not think we should underestimate how potentially complex that can be. It is not just a question of somebody going back home and picking up where they left off.

Having really good support rapidly following up is absolutely essential. We have concerns about evidence of either inappropriate support or lack of support, support that has not been there or follow-up that has not happened. I would want us to be careful about checks and balances here.

Health and Care Bill (Eighth sitting)

Chris Skidmore Excerpts

Committee stage
Thursday 16th September 2021 Public Bill Committees

[Justin Madders]

I am grateful for the Minister’s comments. The Opposition would not want to be accused of being over-prescriptive—that is certainly not what we intend. I appreciate what the Minister said about not wanting to limit the role of ICBs and he made a good point about the vaccine roll-out being a pertinent example of how innovation can be of huge benefit. That may be at the forefront of his mind because there is now a vacancy in the Department in the role of Minister for Covid Vaccine Deployment; the Minister may be looking to add to his already extensive portfolio.

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Chris Skidmore (Kingswood) (Con)]

I beg to move amendment 7, in clause 19, page 17, line 7, leave out from beginning to end of line 9 and insert—

“(a) support the conduct of research on matters relevant to the health and care system,

(b) work with universities and other research settings to support the development of the health research workforce and careers, and

(c) promote the use in the health and care system of evidence obtained from research.”

This amendment would require Integrated Care Boards to work with universities to support research in their local health and care systems.

[The Chair]

With this it will be convenient to discuss amendment 8, in clause 19, page 17, line 13, after “1F(1)”, insert “and work with universities and colleges”.

This amendment would require Integrated Care Boards to work with universities and other education providers to promote education and training in their local health and care systems.

[Chris Skidmore]

The amendments would place a legal duty on integrated care boards to support and promote the use and development of research in their local health and care systems. The existing legislation talks about the health system; this is the Health and Care Bill, so it makes sense that the duty to promote research should also promote research in care settings.

Importantly, amendment 7 would promote and support the conduct of research alongside universities, which drive research outputs and innovation in healthcare. We would all agree that that has been highlighted throughout the pandemic: if it was not for our universities, we would not have all received a vaccine, in respect of which the United Kingdom has been at the forefront of research and innovation.

In the specific context of the Bill, it is important to require ICBs to engage with universities and other research settings on the development of the healthcare research workforce. ICBs will have a vital role in ensuring that we have sufficient numbers in not only the health workforce but the healthcare academic workforce, which is key to overall healthcare workforce sustainability. That is particularly important for the development of the clinical academic workforce. Clinical academics work in higher education institutions, conducting cutting-edge research and educating the future workforce while also providing clinical expertise to health and social care services. Because they remain clinically active, their research is grounded in clinical practice and questions that matter to services and patients.

Data from the Medical Schools Council staffing survey shows that although the total number of NHS medical consultants and GPs has risen by 40% over the past 15 years, the numbers of clinical academic have simply not kept up to pace—in fact, they have decreased, from 7.5% to 4.2% of the workforce. The proportion of clinical academic GPs has remained stable, but at just 0.4% of the GP workforce. Furthermore, less than 0.1% of the workforce in nursing, midwifery and the allied health professions are clinical academics. Increasing clinical academic capacity is essential to advancing evidence-informed practice and innovation in healthcare in the future. The point here is that expansion of the healthcare programme of student numbers on the UK Government’s intended scale also requires an expansion of the number of healthcare academic staff.

The 2019 academic staffing centres of the Council of Deans of Health identify challenges for universities in recruiting staff and an ageing academic workforce in healthcare subjects. In England, 36% of academic staff are over the age of 50, and 9% are over the age of 60. That suggests that the academic workforce is significantly older than the healthcare workforce as a whole. It suggests that, within the next 15 years, almost half of the academic staff will be at or near retiring age, with many already likely to have retired. Without significant renewal of the academic healthcare workforce, not enough staff will be left to keep up with the number of students.

It is key that senior leaders in both the higher education and the healthcare sectors cultivate a culture of support for clinical academics. ICBs, health and social care providers and universities need to work in partnership to support clinical academics and clinical staff interested in secondments or joint appointments to universities. There should be opportunities for clinical staff to obtain experience and skills in teaching and also in research.

Amendment 7 ensures that ICBs remember their responsibilities to research, to local research priorities and to developing a local clinical academic research workforce, and universities are vitally involved in that important work. I think I am the only Member of this House who has been both a Health Minister and a Universities Minister twice. When I went into the Department of Health and Social Care, we were talking about integration between healthcare settings and social care settings. We have a similar problem with integration when it comes to looking at the medical workforce and ensuring that the education settings and the healthcare settings also integrate better together.

Amendment 8 returns to this point. It would require integrated health and care boards to work with universities to promote education and training in their local health and care systems. Universities are committed to co-creating healthcare services through working with practice partners, further education colleges and other stakeholders to plan and deliver the future workforce. I know that, when we come to clause 33, we will be talking about workforce planning at length, but this amendment would help to enable us to plan in advance to mitigate some of the problems that come with workforce planning for the future.

Universities are rooted in their local and regional communities and focus on improving healthcare outcomes and driving up economic and social wellbeing through providing programmes to meet skills gaps in those local areas. This is highlighted through the work of the universities during the pandemic, including the University of the West of England in my own locality hosting a Nightingale hospital, and the deployment of thousands of healthcare and medical students and some academic staff within clinical practice to expand the NHS workforce at the height of the pandemic. We all want to pay tribute to those medical students who, with no extra salary, gave up their time to volunteer to help staff on some of those covid wards at the time.

In England, universities currently sit on local workforce action boards and on sustainability and transformation partnerships to ensure that education is central to local healthcare planning. The amendment ensures that universities and colleges continue to be actively engaged by ICBs to plan and deliver on local workforce needs and priorities to ensure a sustainable workforce. This should take place alongside continued work with Health Education England.

Healthcare programmes are holistic and necessarily constituted of theory and practice components. For example, a registered nursing programme consists of 4,600 hours of education across three years—2,300 hours of academic learning and 2,300 hours of theory learning. Universities and their practice placement partners need to be involved in national and local workforce planning to ensure that there is adequate placement capacity in the system. As I saw when I was a Health Minister, placement capacity has long been recognised as a constraint to sector growth. Even if the hospitals wanted to expand, they did not have the placements to be able to deliver on the demand that was there.

ICBs must be involved in developing placement capacity and innovation and work with partners to increase placement opportunities outside the NHS, including in private healthcare, the third sector, social care, research and teaching, and international exchange. ICBs also need to work with education providers to think about developing education placements to support digital innovation and online and blended delivery, particularly considering the learning we have from the pandemic. That will help to support higher education institutions to manage the continued challenges posed by placement capacity problems, considering health service pressures.

Requiring ICBs to work with universities and colleges is also key to ensuring the success of healthcare apprenticeships and new technical qualifications such as T-levels. Universities work in close collaboration with local employers to develop and deliver healthcare apprenticeships. They are also committed to ensuring smooth articulation between further education and higher education, and universities are working with colleges to ensure that the healthcare T-levels and the new higher technical qualifications are rolled out successfully.

The amendment would ensure that the planning of future workforce numbers and sufficient placement capacity for all learner routes must be developed in partnership with education providers. That is crucial.

[Alex Norris]

I congratulate the right hon. Gentleman on his amendments and the case he made for them. I hope that he remembers with fondness his visit to the University of Nottingham and Nottingham Trent University when he was Universities Minister. He will have seen then the significant role that they play in our community, and I think they provide a good model for some of the things that we are talking about. I hope the Minister will address the points about clinical academics in particular. They were very well made, and I thought the right hon. Member for Kingswood also provided the basis for what will be a really interesting discussion on clause 33.

What attracts me to amendment 7 is that it is really important to send a signal to the leaders of integrated care boards that we want research to be central to their mission, as NHS Providers said in its evidence, and that we do not see them solely as administrators of health and care spending on a day-to-day basis, who every winter have to engage in collective crisis management to keep the lights on. We have much broader horizons in mind for them. If this is about new and enhanced models of more integrated care, we have to harness the expertise of academia. Hopefully, if this was effective and worked as a two-way process, with academics learning from inside the system and the systems learning from best practice from around the different footprints, that would be really powerful.

That relates neatly to the point about inequalities, from the beginning of our line-by-line consideration. The argument in favour of making that a priority was not about some sort of quixotic search for solutions or saying that something must be done, so let us just do something; rather, it is about taking evidence-based, high-quality interventions that work and putting them to work elsewhere. The sort of insights that amendment 7 proposes would certainly do that.

When I read amendment 8, my first instinct was, “I wish I had tabled it,” because I think it is great. We want to foster a culture where we invest in and develop our people. That is true whatever someone’s role is in the health and care service. Of course, that is really important in the NHS, and we all have a clear picture of what that looks like, but it is even more important in social care. We undervalue the role of social care in so many aspects, obviously and most tangibly in pay and conditions, but we also do not invest in people. Imagine how much more attractive a career in care would become if someone’s training prospects went beyond the limited ones offered by whoever their employer happens to be and instead a wealth of other opportunities and courses backed by top higher education providers in their community was opened up.

My family’s life was transformed by the impact that night school had on my mum’s skills. She progressed from being an unqualified person working in childcare and turned that from a job into a career. That was completely transformative, not just for her life but for mine and my sister’s. How terrific would that sort of picture be for people entering the care profession. It would be a wonderful thing. So there is a lot to go at here, and I am very interested in hearing the Minister’s views on how we can try to foster that culture, if not through amendments 7 and 8.

--- Later in debate ---

[Edward Argar]

I am grateful to my right hon. Friend the Member for Kingswood for tabling his amendments and allowing us to have this debate. As has been mentioned, he was both my distinguished predecessor in this role and a very distinguished Minister for universities and research.

Amendments 7 and 8 relate to requiring ICBs to work together with higher education institutions and to their research duty. With the consent of the Committee, and with yours, Ms Elliott, I will start with amendment 8 and revert to amendment 7. Amendment 8 would alter the statutory duty placed on ICBs to promote education and training when exercising their functions to assist the Secretary of State and Health Education England in the discharge of their statutory duties. The Government believe that integrated care boards should promote education and training for people who are employed or considering becoming employed in the provision of NHS services, and that is what proposed new section 14Z41 of the National Health Service Act 2006, in clause 19, achieves that. This provision mirrors the duty currently imposed on clinical commissioning groups. In discharging the duty, ICBs will invariably work with higher education institutions as well as other educational providers as they consider appropriate.

At this point, the Department does not think that it necessary to mandate specific details of how ICBs should discharge that duty under proposed new section 14Z41, particularly as NHS England will have a power to issue guidance to ICBs on the discharge of their functions, which should serve to clarify the system. The draft guidance published by NHS England and NHS Improvement in August 2021 states that the delivery of ICBs’ responsibilities will include working with educational institutions to develop the local future workforce across the health and care system. We believe that that guidance sends a strong signal to the system of the importance of the issue, reinforcing the statutory duty that ICBs will be under to promote education and training. Furthermore, it is worth noting in that context that ICBs will not be the only place in the system where engagement with higher education institutions will be taken forward.

HEE works extremely closely with higher education institutions and other education providers both nationally and through non-statutory regional people boards, jointly with NHS England, to ensure that the education and health systems are producing the right number of people with the right skills for our NHS. For example, Health Education England has already offered to support ICBs through the provision of workforce development support.

I will now turn to amendment 7, before wrapping both amendments together. I start by reassuring my right hon. Friend and other hon. Members who have spoken in this debate that the Government remain fully committed to supporting research as part of our NHS. Currently, clinical commissioning groups are under a duty to promote research; the Bill places the same duty on integrated care boards. That duty is discharged in a variety of ways—for example, with some CCGs having research strategies or research offices, providing details on how people can participate in research locally, or being partners in research organisations. Rather than being direct funders or directly conducting research themselves, the role of integrated care boards is to facilitate and enable research.

A duty to promote research gives greater flexibility for integrated care boards to determine how best and most effectively to engage with and encourage research in their local system. For example, NHS Liverpool CCG is the host organisation for the National Institute for Health Research Applied Research Collaboration North West Coast, while NHS Norfolk and Waveney CCG has a dedicated primary and community care research office, which works with a range of stakeholders, including academics, to develop and support the delivery of healthcare research across the area.

The amendment would modify the research duty on integrated care boards by replacing a requirement to promote research on relevant health service matters with one to “support the conduct” of that research. It also contains an additional requirement for ICBs to work with universities and other research settings to support the development of the health research workforce and careers.

We believe that there would be relatively little practical impact from changing the duty to one of supporting the conduct of research, and that there would be the potential to cause some confusion to staff moving from CCGs to ICBs as to what was expected of them. On the question of developing the health research workforce and careers by working with universities and other research settings, there is a risk in highlighting universities in particular, as that might imply an exclusion of other education facilities, although I know that that is not the intent. Furthermore, I have already highlighted the effectiveness of the proposed education and training duty, which includes the research workforce. Finally, the duty in relation to promoting the use of evidence and research is already part of the existing ICB duties.

I hope that, given those reassurances, my right hon. Friend the Member for Kingswood will not feel that he has to press his amendments to a vote. I look forward to continuing to speak with him as proceedings on the Bill continue, to ensure that when it becomes law, we end up with something that accurately reflects what we need in order to carry on being a powerhouse of innovation and research.

[Chris Skidmore]

I thank the Minister for his considered comments on these amendments. They are probing amendments, and I do not intend to press them to a vote. I hope, however, that the Department will consider not only the discussion that we have had in Committee today, but a letter that was sent to the Minister’s office on 14 September from Universities UK, the Medical Schools Council and the Council of Deans of Health, which have all signalled their support for a form of words in an amendment that recognises the potential difficulties about placement planning and the opportunities represented by putting measures in the Bill about ICBs demonstrating integrated working.

I have been in Bill Committees before—I am now legislating to take out a lot of what I legislated for 10 years ago, when I was dealing with what became the Health and Social Care Act 2012. These Bills do not come around very often, so we have a fantastic opportunity, as the oral evidence sessions demonstrated, and I fully appreciate it. I have removed and re-tabled one of my amendments, to clause 33, as a result of the feedback from the oral evidence sessions.

There is a tension about how prescriptive we should be when the very culture of the Bill is about locally led practice and delivery and ensuring that we give health service managers and clinicians the opportunity to decide what is best for their local areas, so I do appreciate that prescription here may be unnecessary, but I felt it was important that I raised this as an opportunity to make a change in the Bill.

When it comes to clause stand part, I would like to speak more generally on clause 19 about the value of research, which my hon. Friend the Member for Vale of Clwyd has spoken about. I think we have an opportunity—it is one that I do not want to miss—when it comes to embedding research within the future of the NHS. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Alex Norris]

I beg to move amendment 46, in clause 19, page 25, line 37, at end insert—

“14Z58A Power of the Domestic Abuse Commissioner to obtain information

(1) The Domestic Abuse Commissioner may require an integrated care board to provide the Domestic Abuse Commissioner with information.

(2) The information must be provided in such form, and at such time or within such period, as the Domestic Abuse Commissioner may require.”

This amendment places a requirement on Integrated Care Boards to share information with the Domestic Abuse Commissioner at their request.

This is the first of a couple of amendments relating to domestic abuse. I hope it is not necessary, but it is my best avenue for establishing a point. I am really hoping for a one-word answer from the Minister—in my experience, a one-word answer is better than a two-word answer—and I hope that we can make quick progress with the amendment.

In England and Wales, the Domestic Abuse Act 2021 created the post of Domestic Abuse Commissioner, who is in the vanguard of holding to account authorities and agencies to ensure that their process and plans promote our national attempts to tackle domestic abuse. Currently, the post is filled by the excellent Nicole Jacobs. She has the power to obtain information from public bodies such as the local police, the local council and the Care Quality Commission, so that she can express her views as to whether those organisations are acting in line with well-evidenced best practice in the decisions that they take. That is an important way in which we can be assured that public policy decisions on the ground from day to day reflect the national consensus on what we are trying to achieve.

Currently, NHS bodies are in scope of the commissioner’s powers, and I want to clarify that ICBs and any relevant sub-committee would also be in scope. The composition of the boards will not matter, and there will be no shielding behind commercial confidentiality. The body will sit consistently with other, similar bodies, and the commissioner will be able to get the information she needs to do the job that we have asked of her.

--- Later in debate ---

[Justin Madders]

I am grateful to the Minister for that herculean effort in listing all the powers and responsibilities of ICBs. For a permissive Bill, the fact that it sets out 12 duties suggests that the pendulum has swung a little bit further than the Minister was perhaps prepared to admit on Tuesday. Of course, the number would have been even higher had our amendment been accepted, but there we go; a dozen is still an impressive amount. However, it is really about what that means in practice.

The Minister referred to the duty whereby ICBs are required to promote awareness of the NHS constitution. In the context of the debate that we have just had on NHS waiting lists, it strikes me as similar to the scene—it might be familiar to many Members—at the end of each “Bullseye” episode, when the speedboat that the unlucky contestant had not succeeded in getting was brought out, so as to say, “Look what you could have won!” In this case, it is, “Look what the NHS constitution says about waiting times. By the way, we are not delivering on that for you.” That is the nub of some of the duties—how will they be enforced in practice? The Minister referred to mechanisms for NHS England intervention, although we would have liked that to be further strengthened with specific reference to waiting lists.

I note that in proposed new section 14Z59(4), NHS England has retained the ability to terminate the appointment of an ICB chief executive, but also to direct the chair of the board as to which individual to appoint as their replacement and on what terms. That is quite a strong power. The way I read that, if NHS England decides to get rid of someone, it, and it alone, will decide who will replace them. That really goes against the spirit of what we have been discussing for the last couple of days. Would the Minister be able to allay my fears in that respect, or at least put into context the circumstances in which that clause might operate?

I was interested to hear what the Minister said about proposed new section 14Z47 and ICBs’ ability to offer grants and loans on whatever terms they see fit. It now seems that the “B” in ICB stands for bank, or possibly building society. Obviously, at the moment these bodies do not exist in law and so have no capital resources to draw on to create such grants or loans, but of course that will change in due course. Again, will the Minister advise the Committee in what kind of situations that might be a possibility?

Finally, I draw the Committee’s attention to the powers and responsibilities in proposed new section 14Z52, on health and wellbeing boards’ comments about forward plans. Like much of this, it is a process-driven, tick-box exercise where people have to “take regard” and explain why they are not doing something that everyone else has asked them to do. A whole lot of this raises the question: in a disagreement, what are the levers to get proper accountability and change that the whole of the system, apart from the ICB, wants to see?

[Chris Skidmore]

Although I entirely support clause 19 as an essential ingredient of the Bill that will provide certainty and legal confidence to ICBs, I wish to draw the Minister’s attention again to the duty to promote research. The past year has demonstrated the increased engagement, across all healthcare settings, in research and those activities relating to the pandemic.

Research demonstrates the enormous benefits not only to patients, but to organisations that see improved outcomes, lower mortality rates and increased confidence in care as a result of being research-led organisations. It also shows the staggering gross value added that is produced within the NHS—£2.7 billion in 2018-19, through the National Institute for Health Research clinical research network that supports clinical research activities. For every patient recruited on to a commercial trial between 2016 and 2018, the NHS in England received more than £9,000. When a drug is replaced by a new one—a trial drug—there is another saving of nearly £6,000.

Research not only improves lives; we know it saves lives. I am a passionate advocate for expanding our research and development capacity across society if we are to succeed as global Britain. That is one reason we have that cross-Government target of raising the amount spent on R&D, both public and private, to 2.4% of GDP by 2027.

I want to come back to this idea of the duty to promote research. I recall serving on the Bill Committee for what became the Health and Social Care Act 2012, when the duty to promote research was first written into legislation, with the duty on CCGs. That has now been transferred across in the text for ICBs, in proposed new sections 14Z39 and 14Z40 to the National Health Service Act 2006.

As my hon. Friend the Member for Vale of Clwyd mentioned, the duty to promote may not be strong enough. I do not have an amendment to hand, but I wanted to raise this point more generally so that the Minister and his Bill team might give it some consideration. Given that ICSs are established as the strategic system leaders for the NHS and partner organisations to deliver integrated care and take that whole-systems approach, research will have to be a core element of ICSs’ regional plans if we are to maximise the strengths of the NHS, our world-leading science capability and the opportunities I have spoken about.

I therefore urge the Government to consider whether there might be an opportunity to change the duty to promote into a duty to conduct and resource clinical research during the passage of the Bill. It is important to stress that a duty to promote has to be accompanied by the necessary infrastructure: staffing levels, research capability, digital resources, access to services, efficient trial approval processes, the ability to reliably recruit patients, guidance and dedicated staff time for research. The whole idea of “promotion” is doing a lot of heavy lifting. There might be an opportunity for us to be more detailed in creating a duty to conduct and resource clinical research.

Such a duty—this has been raised with me—would present the opportunity that research brings to highlight clinical inequalities within the NHS. We need to be able to measure research activity; we cannot manage or even promote research activity unless we are able to measure it effectively. With that comes the whole question of clinical auditing—making sure that there is an effective auditing process in place to ensure that research-led activities are able to be effectively measured and therefore effectively managed. I am sure that that will be raised in the other place during the passage of the Bill. I act as a canary in the coalmine to provide the Minister with due warning that I am sure these debates will come up during the passage of the Bill in the other place.

Health and Care Bill (Ninth sitting)

Chris Skidmore Excerpts

Committee stage
Tuesday 21st September 2021 Public Bill Committees

[Edward Argar]

The shadow Minister is an able parliamentarian. I hesitate to say with certainty, but my belief is none at present. However, I caveat that by saying I would not wish to mislead the Committee. If I have got that wrong, I will of course let him know.

There is nothing that stops the evolution of trusts into foundation trusts, if they so wish and meet the criteria. What we are saying here is that it is not one size fits all. We will not force anyone down that route, but the option remains for NHS England. I would argue that the way the system has evolved is a reflection of the strength of that system and the framework that we have put in place around it. On a serious note, I know that the point about foundation trusts is of considerable interest to the shadow Minister. When we reach clauses 51 to 57, which cover this issue and the operation of foundation trusts, I suspect that we may get into rather more detail about how they actually operate. I might even be able to confirm that my understanding of the figure for which he asks is correct.

The shadow Minister has made his points clearly, but I hope the Opposition will agree to these clauses. They are technical clauses in essence, and the shadow Minister has rightly used them to air broader issues that are related. They are technical clauses to reflect the reality of the evolution of the system.

Question put and agreed to.

Clause 26 accordingly ordered to stand part of the Bill.

Schedule 5 agreed to.

Clauses 27 to 32 ordered to stand part of the Bill.

Clause 33

Report on assessing and meeting workforce needs

[Chris Skidmore]

I beg to move amendment 94, in clause 33, page 40, line 6, leave out from beginning to end of line 11 and insert—

“(1) The Secretary of State must, at least once every two years, lay a report before Parliament describing the system in place for assessing and meeting the workforce needs of the health, social care and public health services in England.

(2) This report must include—

(a) an independently verified assessment, compliant with the National Statistics Authority’s Code of Practice for Statistics, of health, social care and public health workforce numbers, current at the time of publication, and the projected workforce supply for the following five, ten and 20 years.

(b) an independently verified assessment, compliant with the National Statistics Authority’s Code of Practice for Statistics, of future health, social care and public health workforce numbers based on the projected health and care needs of the population for the following five, ten and 20 years, consistent with the Office for Budget Responsibility long-term fiscal projections.

(3) NHS England and Health Education England must assist in the preparation of a report under this section.

(4) The organisations listed in subsection (3) must consult health and care employers, providers, trade unions, Royal Colleges, universities and any other persons deemed necessary for the preparation of this report, taking full account of workforce intelligence, evidence and plans provided by local organisations and partners of integrated care boards.”

This amendment would require published assessments every two years of current and future workforce numbers required to deliver care to the population in England, based on the economic projections made by the Office for Budget Responsibility, based on projected demographic changes, the prevalence of different health conditions and likely impact of technology.

[The Chair]

With this it will be convenient to discuss the following:

Amendment 2, in clause 33, page 40, line 6, leave out

“at least once every five years”

and insert “annually”.

This amendment would require the Secretary of State to publish a report on assessing and meeting the workforce need annually.

Amendment 40, in clause 33, page 40, line 7, leave out “the health service” and insert “health and social care services”.

This amendment would require the Secretary of State to publish a report on assessing and meeting the workforce need for both health and social care services.

Amendment 41, in clause 33, page 40, line 11, at end insert—

“(3) Health Education England must publish a report each year on projected workforce shortages and future staffing requirements for health and social care services in the following five, ten and twenty years.

(4) The report must report projections of both headcount and full-time equivalent for the total health and care workforce in England and for each region, covering all regulated professions and including those working for voluntary and private providers of health and social care as well as the NHS.

(5) All relevant NHS bodies, arm’s-length bodies, expert bodies, trade unions and the National Partnership forum must be consulted in the preparation of the report.

(6) The assumptions underpinning the projections must be published at the same time as the report and must meet the relevant standards set out in the National Statistics Authority’s Code of Practice for Statistics.

(7) The Secretary of State must update Parliament each year on the Government’s strategy to deliver and fund the long-term workforce projections.”

Amendment 42, in clause 33, page 40, line 11, at end insert—

“(3) The annual report must include an assessment by the Secretary of State of safe staffing levels in the health service in England and whether those levels are being met.”

[Chris Skidmore]

I wanted to speak to amendment 94, which is the product of a revision on my part. I initially tabled an amendment to clause 33, but it was as a result of the oral evidence sessions when the clause was discussed at length by a number of organisations that I decided to re-table amendments with further detail.

Clause 33 is one of the shortest clauses in this substantial Bill, but it is one of the most important. When it comes to looking at how we plan the NHS workforce for the next five years as the clause suggests, or the next 10 or 20 years, we face significant demographic changes in the United Kingdom. We have an aging population with sadly more co-morbidities and chronic conditions, such as diabetes, than ever before, which puts increasing pressure on not only the health service, but the health and care service. That is the omission. The clause has no mention of the care service, which needs to be dealt with.

The clause is rather perfunctory. At the moment, the duty on the Secretary of State is to,

“once every five years, publish a report describing”

—not necessarily detailing or taking any action—

“the system in place for assessing and meeting the workforce needs of the health service in England”

—not the care service.

Secondly, the report would be prepared by NHS England and Health Education England alone, not mentioning any of the other wider workforce organisations. They would,

“assist in the preparation of the report”

but only,

“if requested to do so by the Secretary of State.”

The Secretary of State holds all the cards about how the report is published and what type of data is used.

Amendment 94 sets out that we should have a report every two years. The first amendment I put down actually wanted an annual report. I know there are some amendments on annual reports, but it was very clear from organisations, such as NHS Confederation and NHS Providers, that they saw an annual report as being too bureaucratic. They would have to start the next report having just finished the previous one, hence I withdrew the amendment. In that spirit of the Committee, it is important that Back-Bench Members listen and change our amendments where possible.

I have tabled some amendments saying that the Secretary of State must lay a report every two years. We have seen with the pandemic that five years is too long a period to anticipate unknowable events and uncertainties within the system. Having a two year report would reflect better on the pressures that can occur within a system over a shorter period of time. Amendment 94 also addresses two specific issues around what this report would look like and how it is put together, because ultimately a report is only as good as the data it utilises. Where are we getting that data from? If the clause allowed NHS England and Health Education England simply to assist in the preparation of the report without any understanding of what data measures are used in such reports, we would miss an opportunity to embed detailed demographic research into our understanding of the workforce needs of the NHS and care population.

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[Karin Smyth]

The right hon. Gentleman is making some excellent points. He and I share a health economy, two universities and a thriving region, but we still have problems. People in my constituency cannot get the sorts of jobs and apprenticeships that they need. How would his amendment deal with the geographical discrepancies across the country through a single two-year report, and how would we account for the different training demands in different parts of the country?

[Chris Skidmore]

I think there is a subsection here about how clause 33 relates to clause 19 and the duties on ICBs as the placemaking organisations that can provide the training opportunities for the future. I also think there are great opportunities in the Department for Levelling Up, Housing and Communities for potential further devolution of the skills budget through a mayoral system. That skills budget will already be devolved in some of the metro Mayor areas, so I hope that it will also be devolved across wider areas that do not necessarily have a city population. The Government are clearly looking to fill that gap. Those are also the skill needs of the healthcare population, which is why, when it comes to the duties for the ICBs, I am keen that they take on board the wider non-healthcare resident population, whether in universities, colleges or elsewhere, to bring in expertise on creating training pathways for the future.

Without going off-piste, I think there are future opportunities for more flexible qualifications. We have the lifelong learning allowance. We are looking at how to allow individuals to retrain for the future, creating apprenticeship opportunities, in-work opportunities and course-based opportunities. This is not just about providing nurses and doctors; it is also about allowing nurses to move up the scales and retrain when they are in the NHS, which would help to lower the attrition rate.

Retention is one of the greatest challenges we have—it is not only about training—and I am sure that the intention of clause 33 is also to get to grips with retaining the 20% of the workforce who leave over a five-year cycle. It would do so much better if it took into account statistics consistent with the Office for Budget Responsibility’s long-term fiscal projections and if we were able to look at the needs of the population. That is what subsection 2(b) of my amendment suggests—looking at workforce numbers

“based on the projected health and care needs of the population”

as well as the demographic numbers of the workforce.

The amendment suggests a number of organisations that should be able to contribute to the report, including health and care employers. I return to the point that the care sector is not reflected in clause 33, and it really should be. Trade unions also play a vital role in identifying needs; that may be strange coming from a Conservative MP and I may disagree politically with unions, but they have the data and the opportunity to provide feedback from their members, which is really important. I have mentioned the royal colleges in discussions on previous amendments. Universities are critical for identifying ways of integrating healthcare and education practices. I also suggest

“any other persons deemed necessary for the preparation of the report, taking full account of workforce intelligence…and plans provided by local organisations and partners of integrated care boards.”

The amendment would therefore allow for place-based opportunities, as the hon. Member for Bristol South has said, in delivering on the clause’s workforce planning.

I do not intend to push the amendment to a vote. It is a probing amendment, which I hope the Minister will take seriously, especially given the length of time the issue was discussed in the oral evidence sessions.

I am sure all Members have received briefing packs from various organisations. Clause 33 comes up as one of the priorities. The organisations’ intentions are not vexatious; they are not raising the issue to make a campaign point against the Government. The tone of the Bill is one of collaboration and partnership. As was mentioned in the oral evidence sessions and the early sittings of the Committee, the Bill is unique. It is not a top-down reorganisation—it is filling in the jigsaw puzzle that has been constructed from below upwards, providing the legislative cherry on the top of a cake that has already been baked by local healthcare communities who know what they need. What they need is certainty on workforce planning. The Bill provides the legislative certainty of consistency at national level that will trickle down to local level.

I urge the Minister to listen to the requests for more frequent reporting on workforce planning, better use of data in producing the report and a widening of opportunities to be partners in that report. The Minister and Department have done a fantastic job in allowing the partnership model to evolve. We have moved away from institutional top-down accountability, where there was a competitive spirit between institutions. We have broken that down; the ICPs and ICBs now provide an opportunity for greater partnership working, for the benefit of patients and the outcomes that need to be delivered. This is the missing piece in the legislation.

We need to move workforce needs to a partnership model and away from the top-down approach that clause 33 very much suggests. The Secretary of State holds all the cards on the planning of the report and does not even necessarily have to work with NHS England or Health Education England. In the spirit of the Bill, I urge the Minister to open up the clause and consider the proposal in amendment 94 on Report or in the other place. It is an important change that would make the Bill even better. I urge him to give it due consideration.

[Justin Madders]

I will speak to amendment 94 and the other amendments in my name and the names of my hon. Friends, since they are grouped together and we are clearly all talking about the same thing. There is probably only a cigarette paper between many elements of these amendments and, I hope, the Minister’s position when we get to the end of the debate.

One reason why there are so many amendments and they are all fairly similar is that it was clear from the evidence sessions that this is one of the few areas on which there was complete agreement among the witnesses. Clause 33 is simply nowhere near good enough. Given the importance of workforce issues, which is the most crucial issue facing our NHS and social care system—as the right hon. Member for Kingswood mentioned, social care must be included within this—it is strange that we have really quite a tepid offering in the Bill.

It feels as though the whole question of workforce is firmly in the Department’s “too difficult” box. It knows it has to do something; it knows that without the tremendous efforts of the staff the NHS would simply collapse, but rather than coming up with an effective strategy, it has produced this fig leaf of a clause to create the impression that the issue is being taken seriously and dealt with.

--- Later in debate ---

[Edward Argar]

The hon. Lady alludes to it not being normal form for a Whip to intervene, but her contribution is, as ever, extremely valuable in this context—particularly given the work that she did before she became a Member of this House—and I am grateful to her. My counterpoint would be that we need to be cautious about a separation of projections and planning from the reality of day-to-day delivery. The system, as envisaged, will bring together an actual knowledge of what is going on on the ground with those projections and data delivery.

I suspect that I will not convince the hon. Lady, but I recognise and acknowledge the expertise that she brings to the area. Back in my days as a councillor, I was a cabinet member for adult social care and saw at first hand the amazing work done by care professionals and by volunteers in the care sector. Notwithstanding any political disagreements we might have, I pay tribute to her for that.

Finally, regarding the consultation requirements in amendments 94 and 41, I assure the Committee that consultation already happens throughout the workforce planning and delivery process. To give a recent example of such engagement, HEE completed a call for evidence as part of its refreshed “Framework 15”. That call for evidence closed on 6 September and received responses from a wide variety of bodies. Between October and April of next year, engagement and consultation will continue through various events led by HEE. I am sure that as I assume my new responsibilities, I will occasionally be questioned on those by the shadow Minister, either across the Dispatch Box or in written questions and letters, as is his wont and, indeed, his right.

At local level, ICBs will be under various workforce-related responsibilities and obligations, as I have set out. As part of that work, we can expect ICBs to work with local stakeholders in their area. We expect all this stakeholder consultation to continue, but we want engagement to be flexible, in keeping with one of the principles—the permissive principle—behind the Bill.

Let me turn to the issue of safe staffing. Amendment 42 would significantly amend our proposed workforce accountability report so that it would have to cover an assessment by the Secretary of State of safe staffing levels for the health service in England and whether those were being met. The effect of the amendment in reality would be to require the Secretary of State to make such an assessment but, in so doing, risk detracting from the responsibility of clinical and other leaders at local level for ensuring safe staffing, reflecting their expertise and local knowledge, supported by guidance and regulated by the Care Quality Commission. We do not support the amendment as drafted, for various reasons.

First, there is no single ratio or formula that can calculate the answer to what represents safe staffing in a particular context, and therefore against which the Secretary of State could make an objective assessment. It will, as we have seen over the past year and a half, differ across and within an organisation. Reaching the right mix, for the right circumstances and the right clinical outcomes, requires the use of evidence-based tools, the exercise of professional judgment and a multi-professional approach. Consequently, in England, we think that the responsibility for staffing levels should remain with clinical and other leaders at local level, responding to local needs, utilising their expertise, supported by guidelines from national bodies and professional organisations, and all overseen and regulated by the CQC.

Secondly, the amendment would require the formulation of safe staffing levels against which the NHS workforce could be assessed. I fear that that would be a retrograde step, as it would inhibit the development of the more productive skill mixes that are needed for a more innovative and flexible workforce for the future. That new workforce is crucial to successful implementation of the new models of integrated care that the Bill is intended to support.

The specific wording of the amendment is incredibly broad and would require the Secretary of State to assess safe staffing levels across all healthcare settings, across the whole of England, for all medical and clinical staff. Such a duty would be burdensome not only for the national system but, potentially, locally—for local clinical leaders. It would move us away from that local accountability and expertise.

I assure the Committee that we will continue to engage with stakeholders and hon. Members, including my right hon. Friend the Member for Kingswood, to look closely at this area. I want to reassure Members, including Opposition Members, that we have heard their concerns and the views that they have expressed in relation to workforce in today’s debate and reflecting the evidence of witnesses. I am grateful, as ever, for the tone in which the shadow Minister has raised his concerns and put his points. We will carefully consider these issues and continue to ensure, and to reflect on ensuring, that we work to address them through the Department’s wider work on workforce.

Let me just say, before concluding, that while we were doing the changeover between clauses, I did a very quick check and I believe I was correct in my answer to the shadow Minister that no applications were currently pending for foundation trusts. I wanted to clarify that it turns out I was right—I suspect he thinks he was right in his assumption as well.

For the reasons that I have set out, I encourage hon. Members not to push these amendments to a Division but to continue engaging with me and other Ministers.

[Chris Skidmore]

I thank the Minister not only for his kind words to me personally, but for his considered response to this set of amendments. It is clear that he is mulling over this, and I would like to give him time to think about potential opportunities for changing the clause. I know how these things work; I have sat in the very same seat that he is sitting in. I know he has to spin off various pieces of paper that have been provided to him by departmental officials. The officials who are sitting here have listened to this debate and will want to go back to the Department to discuss with their colleagues what has been mentioned in Committee today.

There is a gap between the sector’s expectations of what workforce planning might look like and what is currently written in the Bill. The Minister has proven my amendment to be defective. It is already highlighted in the legislative remits of Health Education England that it has to consult the social care sector and also the wider sector. I will not press the amendment to a vote, but I do think there is an opportunity. If we can plan in advance and create systemic frameworks, we will save ourselves time—a stitch in time saves nine. We have an opportunity to provide certainty and security for the workforce and to provide a sustainable framework, although I am not sure whether the five years is sustainable.

As I have mentioned before, I was here 10 years ago on the Committee for the Health and Social Care Bill, which became the Health and Social Care Act 2012. We are now removing parts of that, and the Minister at the time, in the very same seat, argued until he was blue in the face that there would be a benefit. We can learn from that experience, but the lived experience of professionals suggests we need to be more frequent in our assessment of the workforce needs of the NHS and the care sector.

We know that the demographic train that is coming down the tracks is going to hit us. We have seen what has happened with gas supply prices and the energy sector; we knew nine years ago that we had only about four days’ gas supply, and yet no action was taken. If we transpose that over here, we know that we face workforce issues, if not a crisis, in the next 10 years. That will all come down the tracks in a perfect storm of increasing healthcare issues, an ageing population and an attrition rate in a workforce that cannot currently keep up with demand.

There are supply and demand issues. We need more frequent assessments to ensure that supply and demand meet each other, and we need investment in the workforce and in training. Although I will withdraw amendment 94, I am keen for the Minister to consider what further action might be taken on Report or in the other place. I beg to ask leave to withdraw the amendment.

[The Chair]

Is everyone content that amendment 94 be withdrawn?

Health and Care Bill (Tenth sitting)

Chris Skidmore Excerpts

Committee stage
Tuesday 21st September 2021 Public Bill Committees

There are a couple of questions that we would like the Minister to answer. How will he ensure that configurations are to the benefit of patients and can take place within a reasonable timescale, given that he may well be the subject of individual lobbying? How will he ensure that decisions taken under paragraph 4(2)(b) of schedule 6 are appropriate for, and acceptable to, patients and the public? What measures will he put in place to ensure that things are dealt with expeditiously and do not drag on for many years, undermining clinical leadership in local areas? Will he publish a review each year of the impact and effectiveness of the powers that he is giving himself under the clause? As I stand here now, I am still not clear why he wants to give himself those new powers. Hopefully he will reflect on those matters. We have a lot of respect for him, and we are trying to be as helpful as possible, but we do not support clause 38.

[Chris Skidmore (Kingswood) (Con)]

I want to speak generally to the clause and the schedule, rather than in support of any amendments. I thank the Minister for setting out the continued role of the IRP and the four tests that have been put in place. I am sure that all of us on the Committee have at some stage in our local communities faced a healthcare service reorganisation. They are very painful processes, as the hon. Member for Bristol South will recognise. We had a reconfiguration across both trusts in Bristol that began, I think, in around 2004 and has yet to be properly completed. They are incredibly painful processes that can leave local communities feeling disaffected and disempowered, whoever is taking the final decision.

We need to think carefully about the potential unintended consequences of the schedule as it stands. I have not tabled any amendments; I just want to raise potential concerns about the detail. In Bristol and south Gloucestershire, Cossham Hospital was provided to the local community by Handel Cossham, who was the Member of Parliament at the time for the east and south Bristol region. He was the only Member of Parliament who, I think, technically died in the Palace; he collapsed in the House of Commons Library and died of a heart attack. I think in those days they could not even claim that he had somehow survived.

Handel Cossham donated in his will land to the people of Kingswood, on which they built Cossham Hospital, named after him. Even before the NHS came into creation, therefore, Cossham Hospital was there, having been built in 1905. The local people of Kingswood, even though it sits in the Bristol East constituency now, felt very passionately that this was their hospital; it was not the NHS hospital. Yet there was a proposal to close Cossham Hospital, which was then reversed. In consequence, the decision was taken to close Frenchay Hospital in favour of a new hospital in Southmead. Frenchay Hospital was meant to become a community hospital, but a U-turn was taken by the healthcare authorities at the time—the clinical care commissioning groups and North Bristol Trust, which squabbled over who was in control because the land had been handed over from North Bristol to the CCG.

I benefited, when I was elected in 2010, from the “Save Cossham Hospital” campaign, which saw the very good Labour MP lose his seat. I faced battles when there were promises to put a minor injuries unit into Cossham Hospital and then there was another U-turn. Ultimately, no one has been held properly accountable, but the IRP published a report that demonstrated that North Bristol Trust had neglected its duty to communicate effectively with the public.

It is that element of communication with the public that I want to talk about in relation to schedule 6, because I have concerns. I agree with the Minister about removing the control of the health overview and scrutiny committees, because they became toxic platforms for councillors, who suddenly had to take decisions as local authority members. They did not know anything about them; all they knew was that their seats were at risk, so the committees were becoming highly politicised forums. People were turning up to the councils and demanding that councillors referred things to the IRP.

Perhaps the Minister can comment a bit more about the nature of who is doing the referral and who is contacting the Secretary of State, because the Secretary of State will not necessarily be aware of all the reconfiguration decisions. Who is the active agent who is making the referral to the Secretary of State? Will it be a councillor, a member of the public or a Member of Parliament? My worry is that when we get to election time, the Secretary of State becomes a lightning conductor, and this will electrify decisions. For new colleagues in marginal seats in the red wall, this could be one of the decisions that creates the dynamic by which the general election is fought on various reconfigurations. The Opposition will claim that it is the Secretary of State’s responsibility to deal with the matter and that he has let down local communities. That is the dynamic and toxic discussions that we have to avoid, if the provision comes into play.

I agree that the Secretary of State needs to have more information to hand and the ability to make decisions, but I am concerned about the definition in schedule 6, which states that

“‘reconfiguration of NHS services’ means a change in the arrangements made by an NHS commissioning body…that…has an impact on—

(a) the manner in which a service is delivered to individuals (at the point when the service is received by users), or

(b) the range of health services available to individuals.”

That is so broad that it could include the tiniest change. Mr Jones, a constituent of mine, might say, “Actually, this has impacted on my local provision of healthcare services for me. I want you to start a petition to the Secretary of State to change this.” I wonder whether there could be some conditionality placed within the definition that might touch on an overwhelming community interest, or something that might touch on the detriment of patient outcomes.

I believe that when we make reconfigurations, they are not necessarily done for financial reasons. They are done to deliver better patient outcomes, so we have to find a way for all political parties to demonstrate that when we put trust in professionals to take decisions, they are doing so because they recognise that there are ways in which reconfigurations can lead to better patient outcomes. We have to be able to move people in that journey. It is not just about the money when it comes to reconfigurations, and I understand that. As political leaders, it is worth supporting clinical decisions when they are the right ones for the benefit of patient outcomes, even if they are difficult decisions for us to take. Some reflection of that in the definition of “reconfiguration of NHS services” would be welcome.

Ultimately, it will come down to guidance, which is why the section on guidance is important. The Minister has mentioned guidance being published. Currently, paragraph 8 of schedule 6 only says:

“The Secretary of State must publish guidance for NHS commissioning bodies, NHS trusts and NHS foundation trusts.”

I think we would all really welcome that guidance being extended to the local authority’s health overview and scrutiny committee, so that it can understand what role it is playing within this fiery dynamic.

What we really need to do with the clause is ensure that members of the general public understand what the duties and responsibilities of the Secretary of State are to any reconfiguration, and that they are set out very clearly to start with. Once we start going down the journey of a petition being collected, it gathers steam and therefore becomes a campaign. Suddenly, rather than having the Department of Health and Social Care, we have a new Department called the Department of Health and Reconfiguration Services, which is what we need to avoid. For the sake of the public and the community, we have to be able to demonstrate that reconfigurations will happen—that is the nature of the NHS. Decisions need to be taken when the facts change and the clinical outcomes change, and I recognise that fact. However, we have seen flip-flopping in Bristol eroding public trust. We need to ensure that, from the outset, people understand why the Secretary of State has these powers and the conditions under which he can take decisions, working with the IRP. We would welcome guidance, potentially for Members of Parliament and local authority members, so they are able to have advance conversations when constituents come to them saying, “I want you now to refer this to the Secretary of State” or “I’ve got a petition of 10 people who want to refer this to the Secretary of State.” They will then know exactly the context in which they can consult the Departments.

Those are the only points I want to make. I am not here to support any of the amendments, although I support the clause. I wanted to reflect on things that might be added in order to break down the granularity of detail, provide wider community context and make sure the public understand where the Secretary of State sits in this potential conversation around reconfiguration.

Health and Care Bill (Nineteeth sitting)

Chris Skidmore Excerpts

Committee stage
Wednesday 27th October 2021 Public Bill Committees

[Karin Smyth]

I am afraid that these bodies have not proven themselves good at doing that, and it is not good to have them police themselves, so we need to progress the debate. On the national/local question, I am generally more Morrison than Bevan, so I will continue to plough that furrow, but this is also about being seen to do things properly for local people. My fundamental point remains that as we ask people to spend more money—we are talking about a huge proportion of our GDP, and it will be increasingly so under any Government—we need to be able to demonstrate to them what is done with it, and how and why it is done, and we need to involve the public.

That is my view of the future of the health service, and that is why I will continue to pursue this argument. When it comes to cost, it is a moot point whether this is done quietly in the corridors of NHS England; whether it is done by the Secretary of State; whether names mysteriously appear in the local economy; or whether there is due process. I am not saying that the old system was perfect. It is quite hard to recruit people to these bodies, but they are powerful people, spending billions of pounds of local money in the local economy. They need to be more representative and accountable, and we need to know who they are. As I said, I will not pursue the matter now, but I would like to see it debated further over the passage of the Bill, and we will come back to it another time. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 9

Duty to promote research

“For Section 1E of the National Health Service Act 2006 substitute—

‘Duty to promote research

The Secretary of State must—

(a) support the conduct of research on matters relevant to the health and care system,

(b) provide funding for research on matters relevant to the health and care system, via ring-fenced funding for the National Institute for Health Research, and

(c) promote the use in the health and care system of evidence obtained from research.’”—(Chris Skidmore.)

This new clause would require the Secretary of State for Health and Social Care to have a duty to support, fund and promote the use of research in the health and care system in England, via ring-fenced funding for the National Institute for Health Research.

Brought up, and read the First time.

[Chris Skidmore (Kingswood) (Con)]

I beg to move, That the clause be read a Second time.

The clause would introduce for the first time a duty to promote research, particularly on the Secretary of State. The Committee may remember that in discussion on clause 19, I spoke extensively on integrated care boards’ duties to promote research. This reflects the importance that research plays in our healthcare system. We recognise the value of being able to carry out real-term clinical trials in the single health ecosystem that is the NHS. That not only enormously benefits patients, in terms of health outcomes, but underpins a whole life sciences industry, in which, as we have seen from the pandemic and our vaccine response, the UK is truly world leading.

It is not simply because of profit that I wish to speak to the new clause. It is also clear, as I discussed on clause 19, that research can underpin and strengthen the healthcare ecosystem. It can help with retaining staff, who become inspired by the research that they do in the course of their careers. It also improves health outcomes for patients, and the investment in research is ploughed back into healthcare services. Everyone benefits from spending money on research and development. The hon. Member for Central Ayrshire made the point to me that research also plays an important part when it comes to the accountability and transparency of the NHS by underpinning clinical auditing processes, by which we can then demonstrate healthcare inequalities and map out where NHS services need to improve. That can drive better integration of services by seeking to identify where the inequalities are and closing them.

Promoting research is not simply about R&D and big pharma; it is about changing how we look at our health service. We need to move from a healthcare service that is still primarily reactive to one that can recognise patient population issues around chronic disease, and identify which interventions can be made earlier. That is something that we are beginning to understand far better through the application of genomics and precision medicine. The UK became the first country in the world to code 100,000 genomes in the 100,000 Genomes project, and there is the Biobank project. That has all come about thanks to initial investment in research and development, and it has opened up a whole new area of healthcare services that the NHS will benefit from in decades to come.

It is very important to invest in R&D. Since our morning sitting, the Chancellor has announced an additional £44 billion of investment in the NHS over three years to 2024-25, taking total spend in the NHS up to £177 billion. I welcome that huge investment in healthcare services. It is not yet clear exactly what investment is to go into healthcare R&D, although the Budget leaks in The Sunday Times and beyond suggest that roughly £5 billion of that will be spent on health R&D over five years. I welcome that funding. There was also mention of additional money being spent on genomics.

If it is the case that healthcare research is to receive £5 billion over three years, it is not just about the money; it is about the use that money is put to, and making sure that it goes as far as possible and has the best possible outcomes. We can only do that by ensuring that we have the structures and frameworks in place to make sure that the money is well spent. New clause 9 places a duty on the Secretary of State to

“(a) support the conduct of research on matters relevant to the health and care system,

(b) provide funding for research on matters relevant to the health and care system, via ring-fenced funding for the National Institute for Health Research, and

(c) promote the use in the health and care system of evidence obtained from research.”

The positive feedback mechanism is important. We do not want to commission research that will gather dust on the shelves. We want to make sure, through real-time evidence and clinical trials, that the R&D money goes as far as possible, for the benefit of patients.

I said that paragraph (b) would ringfence funding for the National Institute for Health Research—a long-term ask of research organisations and companies involved in the active process of healthcare R&D. If I am honest with you, the process has often been a hand-to-mouth exercise. NIHR has received about £1 billion a year to spend on R&D. The most important thing in R&D is to provide not simply the funding, but the long-term certainty over that funding. When I was Science Minister, one reason why I was so committed to ensuring that the UK was associated with Horizon Europe was that it is a seven-year multiannual financial framework—those researchers have security for seven years. The level of participation is a different question, but the scientist or healthcare researcher commits to research projects that last several years at a time. What they cannot have is uncertainty, every year, that the research might suddenly be pulled. That leads to the disintegration of research partnerships and a lack of commitment at the start to even beginning to understand what might be achievable.

Ringfencing funding for the NIHR will provide the certainty as well as the money, so it will make the money go further. Individuals will be able to commit to projects, knowing that they have funding not for one year, but several years.

[Dr Whitford]

I spent a few years in cancer research while doing my doctorate. Does the Minister recognise that when there is that hand-to-mouth need to get a publication so as to get another grant, researchers are taken away from what we might call blue-sky or imaginative research that may not work out? People end up researching something they virtually already know the answer to, because that way they will get a publication and then get another grant. It is not just about their personal insecurity—it skews the type of research that gets done.

[Chris Skidmore]

Absolutely. I thank the hon. Member for making that point. When I was Science Minister, we recognised the need to look again at some of the processes that underpin research applications for UK Research and Innovation, for instance. We have the bureaucracy review that is currently being chaired by Adam Tickell, current vice-chancellor of the University of Sussex who is moving on to the University of Birmingham. We need to end this cyclical process of time—which is ultimately the greatest commodity that anyone has to offer—being taken away from researchers whose expertise is far better spent focusing on their research in the laboratory or performing clinical trials, and ensure that they can get on with what they do best rather than having to worry about the administrative burden of applying and form-filling every year.

--- Later in debate ---

[Chris Skidmore]

I thank the Minister for his forensic dissection of the new clause; it is greatly appreciated. He makes a strong point about the legal status of the National Institute for Health Research potentially making the new clause defective, and there would be little point in pressing the measure to a vote for that reason. However, to reiterate what I said earlier, it is a goose that will continuously lay golden eggs for the Minister. If he went away to look at how the new clause might be better shaped to deliver on the priorities and frameworks that he has just mentioned, I am sure that he would be richly rewarded in turn, particularly by all the organisations that recognise the value that research can bring, and by patients and staff, who would welcome the certainty arising from placing future research operations on a statutory footing.

I am a generous person. I remember tabling a ten-minute rule Bill back in February calling for the banning of essay mills in universities and other educational settings. The Government gave a similar response—the proposals were slightly defective in who they covered—but they have now tabled their own amendment to the Skills and Post-16 Education Bill to ban essay mills. That goes to show what can happen when we take the time to table amendments, either through ten-minute rule Bills or in Committee. I say to any Back Bencher, “You are not going to get in trouble with the Whips, trust me.” It is important that we use our parliamentary and democratic duty to push ideas forward, because someone will eventually take them up, whether in this or another Government.

I hope that, when the Bill reaches the Lords, the Minister will reflect on and look at this as an opportunity to deliver significant reform to the health service. For the reasons that I have outlined, I beg to ask leave to withdraw the motion.

[The Chair]

Therein lies a lesson for us all.

Clause, by leave, withdrawn.

New Clause 11

Consultation with staff and patients on service changes

“(1) The Secretary of State must consult staff, staff representatives and patient representatives on any changes in services which fall within the definition of reconfiguration of services or which impact on the roles of more than 20 staff and publish the results of the consultation.

(2) NHS England, ICBs, NHS Trusts and FTs must publish a response to the results of consultations undertaken under subsection (1) and have due regard to the outcome of any consultation.

(3) Where significant changes to services are proposed by any NHS body, that body must produce a business case using the Five Case Model recommended by Her Majesty’s Treasury, or other requirements as set out in guidance prepared and published by the Secretary of State under this section.

(4) The business case mentioned in subsection (3) must be published for consultation and the responses to the consultation taken into account when a decision is taken whether to implement the change.”—(Justin Madders.)

Brought up, and read the First time.

--- Later in debate ---

Brought up, and read the First time.

[Chris Skidmore]

I beg to move, That the clause be read a Second time.

[The Chair]

With this it will be convenient to discuss new clause 28—Duty as to education placement capacity and innovation—

“(1) The National Health Service Act 2006 is amended as follows.

(2) After section 1F(1) insert—

‘(1A) To meet the integrated workforce requirements of integrated care systems, the Secretary of State must—

(a) ensure that there is sufficient placement capacity in the health and social care system in England to educate and develop a sustainable health and social care workforce,

(b) support, fund and promote the use of innovation in healthcare higher education to meet health and social care workforce needs, including new approaches to interdisciplinarity, digital technology and simulation, and

(c) consult universities, health and social care service employers, providers and other persons deemed necessary to develop practice placement capacity and innovation in higher education for health and social care to meet the needs of the health and social care workforce.’”

This new clause would require the Secretary of State for Health and Social Care to develop and support education practice placement capacity across integrated systems and to support innovation in higher education for health and social care.

[Chris Skidmore]

Thank you for allowing me to speak to these two new clauses together, Mr McCabe. They are essentially interrelated and were the product of a roundtable that I put together and hosted with Universities UK and the deans of medical colleges in my role as co-chair of the all-party university group. These were the two asks that the universities and medical colleges had for the Bill. I offer these new clauses as part of that consultative approach, so I will not be pushing them to a vote.

Basically, we are at a crux. I raised this question on clause 33 of the Bill, but when it comes to workforce planning and training, we take a siloed approach, focusing on what the Department of Health and Social Care, NHS England and Health Education England set out as their vision, and the funding flows from that. Not included in that vision, although clearly there are consultative opportunities, is a recognised role and responsibility in legislation for healthcare education providers, the universities and the deans of the colleges in providing the clinicians, doctors and nurses of tomorrow. Nor is there recognition that the workforce is changing. While we have the Government’s commitment to the retention of nurses and doctors, that retention can take place only if there is continuous professional development.

When I was a Health Minister, I was very concerned to ensure an uplift in the budget of Health Education England to 3.4% to match that of NHS England. It had always been thought of as the poorer relation; the money would always flow later, and it took a great deal of lobbying from the relevant organisations to make the point that we needed to put that workforce training money aside, particularly for continuous professional development.

New clause 27, in summary, reflects the fact that if we are to have an integrated care system, and if the new White Paper is to look at how to integrate social care with healthcare, we will need to provide huge retraining opportunities for both NHS and social care staff to enable them to work across whatever that new landscape may be. I do not think it is practical to send everyone back to university, or even always to have physical in-work training opportunities, important though those may be. We will clearly need to have digital opportunities, online courses and a whole technological revolution in how we deliver those retraining opportunities.

Those opportunities are out there. If we look at the universities and the role of EdTech, it is important that the health service grips that opportunity with both hands while it has the chance to do so, because it will be coming down the tracks. If we want to implement reform via the integration of services, it will only be as good as the people working in those services, as we all know, and those people will be as good as they can be only if they are given the appropriate opportunities to train and retrain during their career.

The need for new clause 28 has become more pressing as a result of recent developments. It sets out a duty for education placement capacity; I will not go into the detail of the new clause, but effectively it is about place planning and ensuring that the universities and royal colleges are involved with that at the very outset. In the debate on clause 33, I talked about the paradox of our having a cap on places, which is causing a bottleneck in post-18 education—those pupils who are desperate to become doctors or nurses, but who find a cap on their aspiration.

That cap is there, as we know, because medical places are expensive; they cost not £9,250 a year, but more like £70,000 over the course of a medical student’s training lifetime. At the same time, however, we have a cap on places for those 18-year-olds entering the system and then—surprise, surprise—we find we do not have enough doctors and nurses in the system, and we have to start retraining from abroad.

[Dr Whitford]

Obviously, there has been a drive to expand medical student places in universities right across the UK, but one part of the system that is controlled centrally is foundation places, which a medical graduate has to spend their first two years in. This year, for the first time, there was a shortfall of about 400 places. Hopefully all those graduates have now got a foundation doctor place, but they cannot practise outwith a foundation place, which lasts two years, so they simply cannot work as doctors, nor can they work as doctors until they complete that two-year foundation role. There is no point in expanding medical school places if those at the end of the production line get turfed out to be unemployed or go and work as something else. It is not just about university places; there is also the issue of placements as foundation doctors for the first two years of their career.

[Chris Skidmore]

The hon. Member is absolutely right. When it comes to the foundation year, I was interested in looking at what future reform might come in the workforce. We would need to work with the royal colleges and vested interests on a replacement, or at least on what could make the foundation process more flexible so as to allow in-work training on that foundation year pathway. That is a huge opportunity, and, if I was still a Minister, I would be pressing for a White Paper to look at how we could deliver workforce innovation, because I do not think we can continue to sustain our trajectory using infrastructure and systems designed in the early to mid-20th century. There is a balance to strike, in that we need to ensure that the safety of patients is accounted for, but technology and training has moved on to a different space. We do not see this constriction in other countries, which can offer fast-track routes through medical training processes, particularly post degree and into the foundation stage.

The issue of placement has become incredibly pressing—it is actually a real-time issue. During the pandemic, because the grade threshold was lowered and teacher assessment was used, an additional 1,900 students were accepted to take up medical places in September 2021. Whatever we think about that, those students were all given a place because they had achieved the right threshold, but to train them, an additional £60 million is needed. However, the Government have capped the training budget at £30 million, so although students have been accepted on to courses, universities are finding that they must make a loss of £2,460 per student in the academic years 2020-21 and 2021-22, and the Government are not opening their books to change that cap on finances.

The cap is therefore returning from this coming year, and as a result 1,000 fewer students will be trained each year. In effect, we will see a reduction in the number of students coming on board to be trained. There is currently this one-off moment that universities are taking forward, but as a result we will go backwards when we know that we need more doctors. The demographic changes that I spoke about in debate on clause 33 are coming down the tracks, but we will end up just recruiting from abroad. It is not that there is necessarily anything wrong with those qualifications; I would just prefer a sustainable and, in effect, sovereign pathway.

The post-Brexit narrative is that global Britain will ensure that we can stand on our own two feet and have a sustainable skilled workforce. That could be recognised if we had a placement strategy for medical students. However, we can do that only if we involve the universities and the education sector. The problem is that the Department for Education controls the purse strings for that budget, and I do not think that it realises the long-term consequences on our healthcare system.

The new clause would close a loophole that is kneecapping the Minister and the Department of Health by placing artificial caps on aspiration and—worryingly —on the future number of doctors entering the healthcare system. I will not press my new clauses to a vote, but the issue is extremely pressing. We will see 1,000 fewer students enter medical places next year than did so this year; and students going through the system have no funding for their places, despite having been given those places. That is a real-time issue that has resulted from the wider policy issue not being resolved. The new clauses would help resolve it, but I will not push them to a vote.

--- Later in debate ---

[Edward Argar]

I am grateful to the hon. Lady for clarification, but she illustrates that placements, both as students and in the context she describes, are vital to enable students to understand and learn the reality and skill of their profession. It is also important that placements are rewarding for students.

HEE has successfully worked with education providers and placement providers to ensure there is sufficient placement capacity for the record number of nursing students that we now have. Such work includes payment of the education and training tariff, which pays a contribution to the costs of providing placements. The Government have also supported HEE through the provision of additional funding, enabling it to launch its clinical placement expansion programme. The programme has seen HEE commit £15 million to fund additional clinical placements across nursing, midwifery, allied health professionals and healthcare science in 2021-22. This funding will increase the number of placements offered to nursing, midwifery and AHP healthcare students from September 2021, which was last month, and it will enable HEE to deliver the future health and care workforce in sufficient numbers, and with the skills that the NHS needs.

Before I turn to innovation, I will address two points that were made by my right hon. Friend the Member for Kingswood and alluded to by the hon. Member for Nottingham North. First, the shadow minister touched on those who come from abroad via normal immigration routes or as refugees, the skills they have and how we need to make it easier for such people to utilise their skills and work in our NHS. He is absolutely right, and we continue to look at how we can make the process easier. We need to balance that with making sure that we can evidence and reference those skills for the safety of patients and those qualifications, but where that can be done and where those skills are commensurate, we need to make it as easy as possible for them to requalify or go through the necessary safety processes to be able to work in our NHS. The only other thing I would say is that we have to be very careful that any recruitment is ethical and that we are not denuding countries of the ability to utilise the skills of clinical professionals in rebuilding their own countries.

The second point made by my right hon. Friend the Member for Kingswood was about the challenges posed for maintaining quality, in terms of people going through relevant courses, and for the operation of the cap. I will not criticise any other Government Department, but he highlights the juxtaposition that often occurs between the Department for Education and the Department of Health and Social Care, or between other Departments where two Departments have an interest in the same policy but different incentives for their policy making. There will always have to be a financial test. There is always a limited budget, and my right hon. Friend highlighted how expensive some of the training courses are. However, it is right to expand the number of medical schools and training places, as we have done—he probably presided over it.

I remember going to the University of Lincoln, when I had just been appointed. Those I met were disappointed that I was not my right hon. Friend, but they were none the less very welcoming to me. The University of Lincoln works very closely with the University of Nottingham, which is in the constituency of the hon. Member for Nottingham North, in setting up a new medical school and drawing on the curriculum and expertise that was already in Nottingham. It is a great example. I very much hope that, when I am not in this Bill Committee, I might be able to go once again to visit the University of Lincoln and perhaps come and see the hon. Gentleman’s local medical school over in Nottingham.

Finally, on innovation, HEE currently works with universities, training providers and regulators on the curricula for the healthcare professions to ensure that they reflect the latest technological innovations. Although curricula are set, as I have said, at institution level, HEE can influence the content by representing the employer voice, to ensure that the training that individuals receive is relevant to what employers need.

In relation to consultation, HEE already works with universities, placement providers and others on the availability of placement providers to assess and ensure that there are the right number and types of placement. As I have mentioned, the number of placements has expanded. That is a direct result of the constructive dialogue and engagement that HEE has with placement providers. At ICS level, national guidance on the ICS people function set out the expectations.

I hope that I have set out that work on the areas highlighted by my right hon. Friend the Member for Kingswood is being taken forward—some of it was started by him a few years ago—under the existing statutory duty under section 1F of the NHS Act 2006. Therefore, at this point, we do not think that further specific duties are necessary, but I suspect that, in the further passage of this legislation, we may well return to the sort of themes that we have discussed today.

[Chris Skidmore]

As I said, I will not push the new clauses to a vote, but I will just reiterate that there clearly is a massive structural supply and demand imbalance. I do not believe that the status quo will be sustainable in the longer term. I do appreciate the Minister setting out the ecosystem as it exists, but I fear that that ecosystem, in the longer term, cannot keep up with the changing demands on the healthcare system and the expansion of the healthcare system thanks to the budgetary announcements today about the amount of money that is being spent. None of this will cut through effectively if we do not have the trained workforce in place to be able to deliver healthcare on the ground. Mention has been made of general practitioners and the shortfall that we are going to see as a result of the demographic and retirement bulge that is going through the system at the moment. These are problems coming down the track, and I would always recommend in policy, as in life, that if we see a problem and know that we are going to have to take a decision, it is better to take the decision sooner rather than later, because the costs will only be less now and greater later on.

I will not push these new clauses to a Division, but I have, Cassandra-like, sent out a warning cry of what will happen in the future if we do not act soon. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

Ordered, That further consideration be now adjourned. —(Steve Double.)