NHS Workforce: England

Eleanor Smith Excerpts

Wednesday 17th July 2019 Westminster Hall

[Eleanor Smith (Wolverhampton South West) (Lab)]

I beg to move,

That this House has considered the legal duties of the Secretary of State for Health and Social Care for NHS workforce planning and supply.

I am a nurse. My daughter is a nurse. Nursing is in my family and fundamentally informs who I am and what I do. Last November, I triggered a debate about investing in nursing higher education. I am here today to again carry the burning flag for the nursing profession, the wider health and care workforce, and society.

I will start by directly addressing the notion that we should not seek to further clarify the Secretary of State’s legal duties and powers. I have heard that the latest legislation sought to remove political interference in our health system. I have heard people say, “Don’t make health a political football.” Lastly, I have heard that changing the legislation to give the Secretary of State accountability for the workforce would put health and care back under political control—as if our ability to access health and care was ever out of political control.

I am sorry, but those are laughable positions. Which- ever side of the fence we sit on, it is a serious point that health is fundamentally political. It can never not be political, in terms of what we can access and what happens to people. Our great health service was created within a political agenda, and creating it was a fundamentally political act. Supporting our health and care service to thrive will never not be a political decision. Let us be proud of our history, recognise that health is political, and find a solution to the problems we face.

Now that I have addressed those weak positions, let me state that I, and many others across the political spectrum, take no issue with the idea that there should be explicit clarity in the law about the Secretary of State’s responsibilities. I am not alone in my gratitude for all that our health and care staff do. They work constantly to provide quality care by putting patients at the heart of what they do. In the NHS and the independent sector, nursing accounts for one in 10 of the labour market of the whole of England. We are, and ought to be, a fundamental force to be reckoned with.

Thanks to the scale and urgency of the workforce crisis, many people have been looking into these issues—some of us would say for far too long, and to poor result. We have a long-term plan for the NHS and an interim NHS people plan, so we have seen some movement in the way that agencies work together. However, we have no understanding of what the social care sector needs, and no assurance of workforce funding, which is entirely dependent on the forthcoming spending review and subject to the whim of a new Prime Minister. We do not have a workforce strategy that meets health and care service requirements, or that projects the future needs of the people who live in this country.

The vacancy rate has reached alarming levels, with almost 40,000 nursing vacancies in the NHS in England alone. That is not the full picture. The extent of the vacancies within social care and public health is unclear because it is not mandatory to collect workforce data. It is not possible for services designed with staffing built into their planning to run safely and effectively with so many missing staff.

Fewer people are joining the nursing profession and more are leaving. Since the referendum on the UK’s membership of the EU, more than 10,000 EU nurses and midwives have left the UK workforce. I will not be drawn on Brexit in this debate. However, while we are trying to find our way through the referendum result, frontline staff are propping up the health and care system with no credible assurances that the situation will be resolved. Our professionals are holding on as best they can, but we need to be realistic about what we can reasonably ask of them. They are starting to vote with their feet, and there is not yet the accountability to help us navigate the future that is to come.

This crisis has come about because there is no clarity in the existing legal powers and duties that would ensure that enough staff with the right skills are in the right place at the right time to provide safe and effective care. That is true not just of nursing but of every profession working within our commissioned, taxpayer-funded services, including nurses, medics, psychiatrists, physiotherapists, psychologists, paramedics, pharmacists, social workers, support workers, occupational therapists and dietitians. Literally no one—no one person—is accountable for growing and developing our health and care workforce to meet patients’ needs, now and in future.

The Secretary of State’s current legal duty is to provide a comprehensive service. The Government may say that the Secretary of State has oversight of the workforce through those general duties and powers. With all due respect, the Secretary of State’s responsibilities are too broad to understand what aspects of workforce provision they include. There are also no particular workforce duties within the range of national organisations responsible for service design and delivery. In a health and care system as complex as ours, it is easy for everyone to lose sight of ensuring that we have enough people. Clearly, that is exactly what has happened.

[Mr Jim Cunningham (Coventry South) (Lab)]

Surely two reasons for the number of vacancies are low pay in the public sector generally and the lack of bursary provision to recruit new nurses. Does my hon. Friend agree that there is a golden opportunity for many mature women, whose children have grown up, to enter that profession? Recently, even ambulance drivers had to pay extra for their certification—I had a debate on that a couple of months ago.

[Eleanor Smith]

My hon. Friend is right, and I will touch on the removal of bursaries later.

A huge amount of effort has been required to try to fix this mess. There has been progress in the NHS, but it is too little and too slow. It does not include social care and deals only with the immediate context. Many of us in this House are here to challenge the position that the existing so-called responsibilities are clear and robust enough for use by the Government and the health and care system, and for the public to have confidence that the Government can be held to account—now and in future, since the pressures on the system will continue to grow and change.

Yesterday, many of us met nursing staff, having been brought together by members of the Royal College of Nursing, who are all passionate about patient care and public safety. I am moved by their advocacy for the profession, patients and society. I also feel their desperation in the situation they face, trying to keep people safe in challenging environments. Given that professionals have been raising the alarm for decades, hopefully our demands for an end to the boom-and-bust cycle in the workforce will be met.

Even the High Court recognises how vague the current powers and duties are. The legal dispute between the Secretary of State and junior doctors over their contract resulted in a judicial review in 2016. The Court judgment said that, as stated in the National Health Service Act 2006, the objective of “protecting the public”, with a duty on the Secretary of State to take appropriate steps, leaves

“considerable leeway to the Minister as to ways and means”

of running the service.

Anyone who looks at the content of the law can see clear holes and gaps. In addition to the Secretary of State having no explicit responsibility, we have other problems with the duties and power of the national guidance. For example, Health Education England is the organisation responsible for developing our workforce, but its hands are tied because it does not have sufficient legal powers or funding to invest properly in the educational provision needed to grow our workforce. HEE can do planning but not supply, which ought to be the responsibility of the Government. The current legal framework is simply not fit for purpose.

Some people might say that Simon Stevens, the chief executive of NHS England, should be accountable for not addressing the workforce needs. The development of the long-term plan provides another clear example of the ambiguity and conflicting expectations playing out in practice. In June 2018, the Prime Minister said:

“Growing demand and increasing complexity have led to a shortfall in staff. So our ten year plan for the NHS must include a comprehensive plan for its workforce to ensure we have the right staff, in the right settings, and with the right skills to deliver world class care.”

That was a clear signal of the Government’s commitment that the long-term plan would address the workforce crisis. On publication, NHS England acknowledged significant workforce issues but said that staffing was additional to service planning and was outside the £20 billion financial package that Simon Stevens was given. Again, NHS England does not have any explicit legal duties that relate to the workforce, so it is not obliged to act.

Just last week, Simon Stevens said there is a need for a

“much bigger upturn in the pipeline of new nurses… There has been a big debate about bursaries and their removal, which as we look at the way the student loan system is working, that is clearly back in play as a big question we’ve got to answer as a nation.”

However, the reasons for these supply problems are not within Simon Stevens’s control. They include the reform of higher education for nursing, which has not grown as we were promised. The ability to boost and fund the workforce sits with the Government, and the ambitions set out in the long-term plan will not be met if we do not have trained and qualified staff to achieve those goals. Although the Government have committed to transforming services, they must also commit to building the workforce we need. To do that, the lack of accountability must be addressed.

A nurse who walks into a shift that is short-staffed has no power to safely and effectively staff services. They have no option but to carry on, yet the buck stops with them when patient care is unsafe. Nurses have no power to recruit more staff, and they rely on Parliament to ensure that the incredible position we find ourselves in is addressed; to fix things not just now, but for the future. I know how heartbreaking it is for a nurse to be unable to give the care they want to. I know the guilt we feel when care is left undone, and the stress of being unable to do our job to the best of our ability. Patients pay the highest price when the number of nursing staff falls too low.

Understanding that the health and social care system is a safety-critical industry should be the starting block for any consideration made by the Government. The Royal College of Nursing and other professional and patient organisations have a clear solution. With cross-party support, they are calling for a legal framework for workforce accountability that sets out who in Government and across the health and social care system are accountable and responsible for workforce supply—recruitment, retention and remuneration.

The Secretary of State for Health and Social Care should have explicit powers in law for the growth and development of the health and social care workforce across England. Such accountability would ensure that there are enough staff to care for the number of patients, and that there is an incredible and fully funded workforce strategy. These requirements are not an either/or position; we need both. Alongside the Secretary of State’s accountability, there are other ways in which the responsibilities need to filter down across all layers of the health system. Never again would the system be able to sidestep workforce planning when setting a 10-year vision for the future of our NHS. The ultimate aim in clarifying accountability for the workforce at Government level is to ensure that all health and social care services are of a high quality, and that they are equipped to provide safe and effective care to guarantee patient safety. The current pressure faced by the healthcare workforce puts that guarantee at risk.

Successive Governments have missed opportunities to fix the health and social care workforce crisis. Boom-and-bust approaches to workforce supply have been an afterthought, with the focus on glossy new services and sparkly new plans, rather than on worrying about the staff who are needed to deliver them. That has led to a situation in which the system currently defaults to discussing how to fix the workforce gap. We need to plan strategically for what workforce will be needed to deliver the future healthcare services that have been designed to meet the needs of the population.

An opportunity to rectify the workforce crisis is coming right towards us. NHS England and NHS Improvement have finished engagement work on the legislative changes that they feel are needed to make a success of the long-term plan. Their engagement work sets out proposed changes to the remit of the Secretary of State, but currently these legislative proposals are missing crucial accountabilities. It is down to right hon. and hon. Members to expand the proposals when the law is presented to Parliament. The legislation must include accountabilities for the workforce, because it is too clear an opportunity to miss.

A simple legal change would turn the tide for patients, and support is growing across the political spectrum for a legal fix as part of addressing the workforce crisis. I found myself at a roundtable discussion on this very matter, with a Government Member with whom I share no political allegiance. We found ourselves in full agreement that we must explicitly clarify the responsibility for putting our workforce on a sustainable footing.

As a nurse in Parliament, I commit to seeking the change that is being called for. I hope that others call on Parliament to speak loudly and clearly in adding their voices to ours, and that all right hon. and hon. Members will commit to pursuing change. This is a truly cross-party issue, and rightfully so. There is a crisis and everyone points fingers at others, but ultimately no one is responsible. There are moves to make the system better, but they must be set out in law and strengthened further. There is an opportunity to fix this cleanly and easily. We are not adding burdens, but clarifying mandates. The moment is now—we must commit to ending the workforce crisis once and for all.

--- Later in debate ---

[Derek Thomas]

I am addressing the point the hon. Member for Wolverhampton South West made about the importance of working cross-party, as we will in this Chamber. I will come to the bursary later.

Actually, I will come to that part of my speech now as the hon. Member for Lincoln (Karen Lee) has mentioned it. I was one of the MPs who signed a cross-party letter requesting a royal commission for the 70th year of the NHS, because I believe that although we do not have all the solutions, we should set the tone. That would help to open the door of opportunity for those who work in the NHS. I will come to the bursary, which I have already raised with the Minister; I asked him to look in particular at the impact on mature students. Podiatry in Plymouth, for example, will not be taught from September onwards. In the south west, where the incidences of diabetes and other vascular problems are significant, we need podiatrists, so that is a major problem. The reason given is that most people who go into podiatry do it later on in their careers, and one of the challenges arising from the removal of the bursary and introduction of student loans—I voted for that and regret doing so—is that those who take out the loan immediately lose all welfare and can no longer get housing benefit.

For someone with a young family who wants to study, the student loan, or the grant available for mature students, is just not enough. The Minister is aware of my view because I have raised it before, and there is work to do on that. It is not about financial incentives; it is about making it affordable for people to go and do a fantastic job. As the hon. Member for Wolverhampton South West rightly said, some people bring so much to health and social care and we need to ensure that we take away every possible barrier without creating unintended consequences. I am sure that the Minister will be pleased to address that point later.

I will talk briefly about how Cornwall is responding. I have been very keen to see what we can do in Cornwall to make sure that people can turn up, get training and work and train on the job. For people in Cornwall, most opportunities for training are outside the area, but as we know, people who go into some professions, including in the NHS, tend to stay where they train. That has always been a problem for Cornwall, which has struggled to recruit the people we need. We have set up a health and care academy using the apprenticeship levy. The academy can offer people training and jobs as healthcare assistants. There, they can do 12 hours per week working and studying through the Open University, and will become qualified nurses after four years. As they are already settled in the area and have family there, they are very likely to work for the NHS for the rest of their careers.

That is really positive, but there are some challenges and I have met the Minister to talk about them. One of the challenges is that for hospitals—in this case Royal Cornwall Hospital—to provide that kind of support, they need extra cash. It is not just about the apprenticeship levy, which they want to use and not repay, but about staffing 100 nurses and 100 healthcare assistants at a time, and providing pastoral support and other elements that come with training up staff on a ward or in a hospital. An added pressure is that for a hospital without the staff that it needs, really excellent healthcare assistants are no substitute for fully qualified nurses with a wealth of experience.

There is a problem in this place. I am a skilled craftsman in the building trade but I have put my tools away, despite the desperate need for skilled craftsmen in Cornwall. In this Chamber and across the House, we have lots of GPs and talented nurses. For some reason, we decided to pitch up here instead of continuing in our valuable jobs. I think that we are part of the problem. I am not suggesting that we should all pack up and go home, although we might get more done if we did, so we should consider it.

[Eleanor Smith]

I get what the hon. Gentleman is saying, but I worked for 40 years in the health service and it was because I saw its deterioration that I came to Parliament to say, “This is what’s happening.”

[Derek Thomas]

I said that in humour, which is why I talked about my own skill—or lack of. It is a curious thing, though, to hear people talking about the crisis in staffing when so many of them are in this place.

On a more important note, we are in a tricky situation with the challenges around the apprenticeship levy. In Cornwall, we hope to train 200 nurses using the apprenticeship levy over the next two years—that would address the shortage—but we have to recognise that funding is needed and I know that the Minister is looking at that now.