Health and Social Care Workforce

Daisy Cooper Excerpts

Thursday 13th July 2023 Commons Chamber

[Steve Brine (Winchester) (Con)]

I beg to move,

That this House has considered the Third Report of the Health and Social Care Committee, Workforce: recruitment, training and retention in health and social care, HC 115, published on 25 July 2022, and the Government response, HC 1289, published on 24 April 2023.

Today’s debate could not come at a more timely moment, although when I wrote that line, I did not realise that it would be at an even more timely moment, given the news that we had this lunchtime about the Government accepting the pay review bodies’ recommendations across the public sector. As I said earlier in the House, I welcome that very much and think it is a fair and proportionate response on behalf of the whole economy and all taxpayers. The Government, of course, have to see things in the round. I hope that all unions in the health space will show the same response that we have seen initially from the main teaching unions. I urge them to do that.

Last week we marked the 75th anniversary of the NHS, and the week before that the Government published the much anticipated “NHS Long Term Workforce Plan”. It was very much welcomed. Some 46 organisations posted messages of support for it, so I think it landed well. In the context of the last fortnight, this is therefore a good moment to look back at what the Health and Social Care Committee, which I chair, recommended in our major report last year on workforce issues, and to look forward to see how many of those recommendations have been taken up in the new workforce plan, and what remains to be done.

This follows hot on the heels of our topical evidence session yesterday, where we heard some initial views about the plan from stakeholders; we put some of the already emerging questions to them and to the medical director of NHS England, Professor Stephen Powis. We are particularly grateful to the former doctor and author Adam Kay for coming and speaking to us, and to Alex Whitfield, chief executive of Hampshire Hospitals NHS Foundation Trust, which runs the Royal Hampshire County Hospital in my constituency. I thank them for coming in. The Committee’s workforce report was published nearly 12 months ago, at the end of July 2022. It was the result of a wide-ranging and in-depth inquiry looking at workforce issues, including recruitment, training and retention across the health and social care sectors. I pay tribute to my right hon. Friend the Member for South West Surrey (Jeremy Hunt), the current Chancellor of the Exchequer, for his work then chairing the Committee and since.

As ever, we are as one, and I endorse every one of our report’s findings. That is because it was the result of more than 150 written submissions and an extensive range of oral evidence witnesses from across the health and care sector, who put together the report. Its main conclusions were stark. The report found that the NHS and social care sector is facing the greatest workforce crisis in its history. It noted that, in September 2021, the NHS was advertising just over 99,000 vacant posts and for social care the figure was 105,000.

[Daisy Cooper (St Albans) (LD)]

rose—

[Catherine West (Hornsey and Wood Green) (Lab)]

rose—

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[Steve Brine]

Anybody employed in health and care should be treated properly and with respect, and they should be welcomed to this country with thanks for the work they are doing. If the hon. Lady has specific examples of something—I am guessing she may have from her intervention—I ask her to please speak in the debate and put them on the record.

[Daisy Cooper]

I thank the hon. Gentleman for securing this debate, and I thank him and the Committee for doing the work on the report. He notes that the issues in social care are regrettably much worse than they have been before. He will know that, on 30 June, nine NHS leaders wrote to the Prime Minister calling for a workforce plan for social care. The Royal College of Nursing and others have called for it, too, including my party, the Liberal Democrats. Does he as the Chair of the Committee or the Committee as a whole have a view on that? I know that the Health Secretary has said that the work- forces are different, but I wonder whether the Committee has a view.

[Steve Brine]

We very much do. I will come on to that, but I am happy to address the point straightaway. In getting the NHS workforce plan out, there were four people in that marriage: No. 10, No. 11, the Department and NHS England. The idea of producing another workforce plan for social care causes some degree of deep sigh. That said, it has to be done. When I was at NHSConfedExpo in Manchester last month talking about our integrated care systems inquiry, Patricia Hewitt, the former Labour Health Secretary, and I were talking about all these issues and there is no question: there was a huge response from the room in wanting to see a care plan alongside an NHS plan. The Minister for Social Care is on the Treasury Bench, so she will have heard this exchange. A care plan is even more difficult than the NHS workforce plan, because the vast majority of services in that sector are not delivered by the state. However, just because something is difficult—I could mention the five priorities—it does not mean they do not need doing.

I was just touching on the vacant posts, and both figures have got worse since the report was published. We think there were some 112,000 or so vacant NHS posts in England in March this year. The inquiry that led to our report found that almost every healthcare profession was facing shortages. The impact of that work- force crisis was also clear to see. The report cited, for example, that the waiting list for hospital treatment had risen to nearly 6.5 million in April last year. That waiting list stood at 7.4 million by April this year, and I dare say the strike action in recent months has not helped. I say, “I dare say”, but I know it has not helped, and the figures speak for themselves, which is why I reiterate my call for them, in the Prime Minister’s words this lunchtime, to

“know when to say yes”

to the pay offer that has been made as a final offer today.

The Committee’s report was critical of the Government’s reluctance to act decisively and noted that a workforce plan promised in spring 2022 still had not materialised. It recommended in no uncertain terms that the Government produce

“objective, transparent and independently audited”

plans with workforce projections covering the short, medium and long terms. The reason I stress “audited” is that the House will remember that the now Chancellor and I were among those who voted in favour of an independently audited workforce plan when the Health and Care Act 2022 went through this House. It is credit to the Chancellor that he has driven that agenda through in government. It was announced a couple of weeks ago that the National Audit Office would now do that assessment. We look forward to that and we as a Select Committee will offer the NAO any help we can. It is what we called for.

I am delighted that the NHS long-term workforce plan was published at the end of last month and is here. It is no coincidence that that happened once my predecessor as Chair entered the Treasury as Chancellor. It is a huge moment for the NHS, a big moment for patients and a good moment for patient safety. Patients lie at the heart of the Chancellor wishing to drive it through.

There are caveats, of course, as there always are with me. For example, the Committee called for workforce plans for public health and for social care, as was raised in my exchange with the hon. Member for St Albans (Daisy Cooper). For what it is worth, as I have said in the House before, I think the Government were right to resist the constant tedious calls from people—including me—to get on and publish the plan, because in fact the most important thing was to get it right. I have spoken about the four organisations in that marriage, and I do not underestimate how difficult it was to get the workforce plan out. Now that it is out, we can scrutinise it—of course, that is part of what we are doing today. I know that it takes time to get these things done and it was right that the Government took their time.

The plan is a real sign of hope for patients and for families. There is also hope for the staff who work in the NHS. Our report noted that the pressures on the workforce were having a “real human impact” on the people working in the service, and they still are. It pointed to the fact that

“In August 2021 alone, the NHS lost two million full-time equivalent days to sickness, including more than 560,000 days to anxiety, stress, depression”

and other mental disorders. Adam Kay, who has written movingly about his decision to leave medicine, spoke powerfully about that to the Select Committee yesterday. I refer the House to the transcript of that, if people are interested.

The talk of burnout has become commonplace. Aside from the obvious human impact, the result is a massive impact on retention. That is a vicious circle, which increases the pressure on those who remain working in the service. People can now see the hope part of what I am saying: the cavalry is coming over the hill and there is a plan. That in itself can make a difference. The pay settlement today along with the pension announcement in the Budget and the long-term workforce plan should be seen as a package of measures that I hope gives the workforce some hope that there are better times ahead.

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[Steve Brine]

I see no reason why not. I am always open to argument from Government Members, but in so many parts of our workforce economy, there is a shortage of people wanting to do certain roles. That is not the case for people wanting to go to medical school. I am constantly contacted by people from around the country, and certainly in my area of Winchester and Chandler’s Ford. Many children—often those of serving medics—who are straight A students want to go to medical school but cannot because there are no places. We have made the mental leap to put the places there, and bringing them forward must be possible. The Minister knows that we are on the case, and I place that challenge before her.

On medical degrees, the plan also talks about NHS England working with the GMC. We heard from its chief executive Charlie Massey yesterday about consulting on the introduction of four-year medical degrees. The Committee explored the idea of shortening training periods in its original report; principally that was in the context of postgraduate training, but I fully support it. We currently take international graduates from all over the world where there are much shorter undergraduate training programmes than in the UK. As long as the GMC standards are met, I am very supportive of shortening the medical degree. I have spoken directly and on the record to the chief executive of the GMC about it. Obviously, quality and safety must be paramount, but as long as it is satisfied with the medical licensing certificates that it will issue, we should embrace that, and I am pleased to see it in the report.

I am also encouraged by the emphasis that the plan places on apprenticeships, with a commitment to providing 22% of all training for clinical staff through apprenticeship routes by 2031-32. That is up from just 7% today. In our related report on the future of general practice—because everything comes back to workforce—we called for the Government to provide the funding necessary to create 1,000 additional GP training places each year. The plan pledges to increase the number GP training places by 50%, to 6,000, by 2031-32. Box ticked, win—thank you.

Our workforce report called for reforms to the NHS pension scheme to prevent senior staff from reducing their hours and retiring early—again, a win. The Government have listened to the Committee. Obviously, that was announced in the spring Budget this year and is incredibly welcome. It was the No. 1 ask of the British Medical Association and we responded—something I hope it will remember over the coming days. I also hope the Opposition will come around to supporting it as well. Maybe when the Opposition spokesman has her say today she might reflect on the changes to pensions in the Budget, because they have been welcomed across the health sector.

The plan makes it clear that NHS England will work with the Government to deliver actions to modernise the NHS pension scheme—there is a specific section on that—and that the Department will introduce reforms to the legacy pension scheme, so that staff can partially retire or return to work more easily. That will make a big difference to some staff, including the consultant reconstructive surgeon who gave evidence to our original inquiry. He described his retirement happening “almost against his will” as a result of pension taxes. He said the NHS was “haemorrhaging senior staff” over pension concerns. I am therefore really pleased that the issue is being addressed.

I meet two or three times a year with the presidents of all the royal colleges in my role as Chair of the Select Committee. I wondered whether it might take a while for the announcement in the spring Budget to feed through, but within weeks of the announcement being made, a number of them were reporting to me—I had asked them directly about this—that it had already moved the dial in terms of people making different decisions about leaving the service, so I think that is a good one.

I think the training bit of the plan is incredibly strong—I have given some examples—but on retention, I think the report is “could do better”, as it said in my school reports. We recommended that there should be a review of flexible working arrangements in all trusts, with a view to ensuring that all NHS staff have similar flexibilities in their working arrangements to those employed as locum or agency staff. The plan talks about a renewed focus on retention with improved flexible working options. Although there is clearly a lot of detail still to come, I was pleased to see that on this point, the Government are listening to the Committee. However, we still need more detail on that and on how it ties in with the childcare changes, for instance, that were announced recently in the Budget.

[Daisy Cooper]

I am grateful to the hon. Member for giving way again. I could not agree with him more on the point about retention. We hear a lot about recruitment, but fundamentally we cannot recruit our way out of a retention crisis, which is what we have right across the NHS workforce. Does he agree that we need measures for retention very urgently in the sphere of general practice? The Government rightly say that they are recruiting more GPs than ever before, but we have a bit of a “one in, one out” situation, where the bucket is very leaky and for every GP we are recruiting, another one leaves. We need retention measures right across the board, but very specifically in general practice if we are to recruit more GPs to fix the front door to the NHS.

[Steve Brine]

Yes. One witness at our session yesterday said that the tap is well and truly on but the plug is still half out, which is a very good way of putting it. The recovery plan for primary care published a few months ago is really strong. It is really positive: it talks about wider primary care roles and it has been created in conjunction with the Royal College of General Practitioners. We need to see a fast-paced roll-out of that plan. We need the extra money for community pharmacies to move through the contract fast, so that it moves the dial even faster, because that is critical to the retention of general practice staff, and it is also critical to this winter being better than last. So, yes—point taken.

Another important point to note about the workforce plan is that it is iterative, so it will be refreshed every two years. I guess there are two ways of looking at that and I would appreciate the Minister’s comments. I understand it is at the Treasury’s insistence that it is looked at every two years, which is fine. We can look at it two ways: either the Treasury wants to make sure the plan is ambitious enough and, if necessary, that it is more ambitious so it can put more funding behind its next iteration, or—to look at it the half-empty way—the Treasury may wish to trim back. It is very important that the Department, Ministers and the House make sure that it is the former. The iterative side of the plan is important, and while we are still in the early stages, it is also important that the plan starts to deliver quickly in a practical way for people on the ground. That is why I said what I did about working with the primary care plan.

One of the possible risks to delivery—there are a few, because the plan contains big assumptions and models of numbers—is that the plan is based on a pretty ambitious labour productivity assumption of 1.5% to 2%. During the statement when the plan was put forward, somebody in the Opposition—it may have been the Opposition Front Bencher, the hon. Member for Bristol South (Karin Smyth)—said that the NHS has struggled to achieve that kind of productivity gear change in the past, so achieving it now will be a challenge. That does not mean that it is not the right thing to do, but I would like to understand from the Government what will happen to the projections in the plan—not necessarily today, but as we go forward—if the productivity assessment is not achieved.

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[John Redwood]

That is right. I hasten to add that there are many examples of good practice in the NHS. In the hundreds of trusts, units and management commands in the NHS, there are some very fine examples. In a large organisation such as this, part of the skill lies in spreading the best practice from the places that know how to do things and are doing them well to those that need help or support. They may not be aware of what is feasible, given the resource to which they are committed. I have found whenever I have been involved with something that was not working well that bad management have often made a mistake and appointed some good people but not in the positions of influence and power where they can really make things happen. Where someone is trying to recover something that is not running well, it is often about identifying the people who are good but who may be sidelined, frustrated or not being used properly, and then transferring them into different roles, to give the idea to the others that the organisation can be a good one.

My hon. Friend was hinting at where someone wants to get to if they are leading any organisation. They want success, because success breeds success; people want to work for a successful and happy organisation. If morale is allowed to sink, performance starts to get poorer. If performance sinks, really good people perhaps do not want to be associated with it or they are frustrated that they are not given the power to sort it out. The organisation could then get into a downward spiral, which it needs to avoid.

Let me move on to a slightly tougher message and spoil the party. I take as my text the work that the Chancellor of the Exchequer and his team have been doing and his recent big speech at the Guildhall on productivity. His research revealed that productivity in crucial public services, particularly the NHS, is considerably below its 2019 levels. We are all sympathetic to the fact that there was a major disruption of the NHS’s work for the period 2020-21, and probably we would also expect there to have been difficulties in in 2022 after the impact of a major diversion of effort and activity into tackling the pandemic. We are all very grateful to those brave and talented staff who did what they needed to do to see people through. However, over that period a large additional amount of money was provided, not just for the pandemic, but now on a continuing basis, along with some additional staff, as we have been commenting on, yet we are still not back to the productivity levels we were at in 2019.

As the managers of the NHS go about creating a more contented and happier workforce, in the way I have been describing, they need to say to people, “You are going to be better paid, but we can also look at your promotion, grading and job specifications,” because the good ones should be able to get additional pay and go up the scale into more important jobs. There has to be something for something. The managers have to help the staff to deliver more treatments, consultations and diagnoses, which must be possible because we are not even at the levels we were at in 2019.

[Daisy Cooper]

I have met scores of people working in the NHS at different levels; I am sure the right hon. Gentleman has too. When I talk to them about the productivity gap, they give me two or three clear examples of why there is a productivity problem. One is that there are more sick days because of burnout and exhaustion. It is unfortunate that the Government are cutting funding for mental health hubs, which have been a huge source of help for staff, particularly in hospital settings.

The NHS workers I have spoken to also talk about scanners that are way past their use-by dates and take far too long to get going, and about IT systems that do not speak to each other. They have to use eight or nine different IT systems between wards, or even on one ward, and old computers take too long to set up in the morning. It is that kind of tiresome daily grind. We sometimes know about that here in Parliament, when computers do not start in the morning and things do not work, and people end up getting frustrated.

Does the right hon. Member recognise that the productivity problem is not just about rotas, but about investing in technology, IT and scanners that work, making sure that water is not coming through the ceilings and giving mental health support?

[John Redwood]

I agree with all that. I have been very careful not to criticise the staff; I am talking about a management problem. If there are too many agency staff, then time has to be spent explaining to them how that particular hospital or department works, which would not be necessary if the regular staff had turned up. If there are gaps because of staff absences or people having resigned, that puts more strain on people and the system does not work efficiently.

All my remarks are made in the context of what I said at the beginning about trying to make these jobs more worthwhile and feasible. We need to look at how that can be done, and managers have to answer questions about whether some of them are imposing too many requirements on people that are not directly related to them performing their tasks better. There have to be limits on how much other general management information or other management themes they want to pursue, when the main task is to clear the backlogs and to treat the patients. The patients should come first, second and third, and that is not always possible if managers are making many other demands. So that is where the management teams need to take the organisations.

I was coming to the other good point that the hon. Member for St Albans (Daisy Cooper) makes, which is also well made the workforce plan. We are living through an extremely exciting digital revolution. It may even be speeding up with the developments in artificial intelligence, which could be dramatically helpful. There is a continuing task in the NHS, which sometimes thwarts those attempting it, to make sure technology is applied in the right way and is understood and friendly to use, so that hard-pressed and busy medics can find it a support, rather than a tribulation or a barrier.

Given the NHS’s huge range of data and experience, artificial intelligence should be an extremely valuable support, aiding diagnosis and decisions on treatment. I am not one of those who think that computers can do these things on their own or are about to take over the world. In the model we are talking about, the computer is an extremely important assistant that can do research and produce first drafts—that kind of thing—in a way that speeds up the work and effectiveness of the professional. However, it has to be controlled and guided by the medical professionals, who have the judgment, wider experience and expertise. The quality and speed of what they do could be greatly enhanced with the right kind of AI backup. For example, if they are facing a condition they do not know much about because it is rare, the computer would be able to give them immediate access, one assumes, to the details of what has happened in similar cases, what it looks like and how it might be treated.