NHS Long-term Workforce Plan

Lord Allan of Hallam Excerpts

Tuesday 4th July 2023 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I am absolutely sure that the Minister is as relieved as anyone to see this Statement on the NHS workforce plan before your Lordships’ House today, after many years of waiting and promises of it being published shortly, imminently, or at some time in a very extended spring.

The plan promises much, but it is the delivery that will count and the difference it will make to the health and well-being of the nation. But at the heart of it, its effectiveness will stand or fall on how successfully it joins up with other key aspects of the NHS and social care. It is not just about delivery: the commitment to updating the plan every two years is essential in the hope that it will be a lasting way out of the continuing workforce shortages that have blighted the NHS for many years. Ministers have a lot at stake and are investing a lot of hope in this workforce plan, not least because the lurch from crisis to crisis has to come to an end, with proper consideration of the long-term challenges ahead.

This long overdue plan started and continues its life against a backdrop of chronic NHS understaffing. It is long overdue. If it had been launched eight years ago, it would have been enough to fill the NHS vacancy levels—yet we have had to wait. Instead, the NHS is short of 150,000 staff, and this announcement will take years to have an impact, while patients continue to wait longer than ever before for operations, in A&E, or for an ambulance. While the plan is a positive step, it is only the first step. Much more detail is needed on how the plan will be implemented and what measures will be used to judge its success. What attention is being given to training staff and key leaders in what quality management looks like?

Retention is key, and the plan has little to say about that. The overall staff leaving rate increased from 9.6% in 2020 to 12.5% in 2022. The plan acknowledges the importance of retaining workers, offering more flexibility and improving the culture in the NHS, but it is light on detail about how it might do that. We know that more NHS strikes are planned—and that work culture, bullying and harassment continue to be a real issue, and nearly one in 10 staff experience discrimination. When will there be details on retention, pay and working conditions, such that they can add some detail on how retention might be improved in the NHS?

It is a missed opportunity that there is no social care workforce plan, especially as the NHS workforce plan identifies the impact that delayed discharge due to difficulties securing a social care package is having on patients and staff alike. Without such a plan, it will not be possible to enhance the quality of care and support provided by the NHS—they are inextricably linked. There are currently 165,000 vacancies in social care, an increase of 52% and the highest rate on record. Average vacancy rates across the sector are at nearly 11%, which is twice the national average. What assessment has the Minister made of the impact that having an NHS-only plan will have on the social care workforce? Social care workers already seek jobs in the NHS, where pay and conditions are better. Does the Minister share my concern that an NHS-only plan is likely to exacerbate this situation and the number of vacancies in the social care workforce? Does the Minister consider that this will undermine the ambitions of the NHS plan?

As the King’s Fund rightly observed, the projections are likely to be based on ambitious assumptions. Yet there needs to be realism about the investment in buildings, technology and equipment that is needed to realise productivity gains. Can the Minister say whether and when we can expect plans relating to the various and absolutely crucial aspects of investment? Page 121 of the plan sets out a labour productivity rate of 1.5% to 2% per year. That was never achieved by the NHS or any other comparable health system, so what assumptions are being made in relation to achieving that?

The focus of the plan is crucial. It appears on reading to have been seen through a rather hospital-focused lens, so will the Minister ensure that the lens includes healthcare in the community? At the centre of this plan has to be the patient in all their different facets. In the consultations that took place in the lead-up to the development of this plan, could the Minister advise your Lordships’ House on how patient organisations were involved and which ones were consulted?

It appears that the plan seeks to look to the longer term. As happened in 2000, when the Labour Government of the time produced a 10-year plan of investment and reform which included seeking frequent staff increases, we will look to this workforce plan to make a difference to patients and care and the health and well-being of the nation in the same way as we saw come out of the plan in the year 2000. I look forward to the Minister’s response.

[Lord Allan of Hallam (LD)]

My Lords, I shall try not to be too grudging, as we have been calling for this plan for so long. I start by recognising the enormous amount of work that has gone into this from people working in the NHS and the department over a very long period, but the reality is that the plan is too late for those who are waiting for treatment today and are unable to get it, because the investment was not made in the workforce years ago for it to be available now on the front line. However, the plan certainly is substantive and there is much to welcome in it, looking forward. There are several areas where I hope the Minister can explain the Government’s thinking further.

First and perhaps most importantly, we need a similar, sister plan for the social care workforce. As we have discussed many times across these Benches, health and care work in symbiosis and both have seen too little supply to meet demand in recent years. Can the Minister confirm that the Government have no plans to further reduce capacity in social care by acceding to some of the requests from his political colleagues to limit visas being made available for essential social care staff? Can he say when the Government intend to release a sister plan to the NHS plan dealing with the social care workforce?

The plan also depends on ambitious productivity gains, and these will require certain things to be put in place. First, we need technology that will make life easier rather than more difficult for staff. Will the Minister explain what work is being done to understand how front-line staff in the NHS actually experience the technology they are being provided with, to ensure that we are not setting them back? Technology, when implemented well, leads to productivity increases, but technology poorly implemented can simply add to the frustrations of staff and make their jobs more difficult.

Another key factor in productivity is good management. This is a much less fashionable area to comment on than additional doctors and nurses, but the evidence seems to suggest that the National Health Service is actually quite lean in terms of its management. Will the Minister comment on what is in the plan to boost management capacity so that we can make savings on that other kind of consultant, the management consultant? Far too much is still being spent on externalising management expertise rather than building capacity within the service.

The final area I want to comment on is retention. The plan has hard numbers and new targets for getting new people into training but is much less precise on how we can improve staff retention over the long term. This is of course, quite importantly, a matter of pay and working conditions across all grades of staff. I invite the Minister to comment on some of the press stories we have seen saying that there seems to be some reluctance on the part of the Prime Minister to implement pay review body recommendations in full, something that he himself has said we should rely on to resolve issues particularly around junior doctors. Certainly, understanding that pay is important and that review body recommendations are going to be respected is critical for retention.

We can see that the Government have looked very closely at the specific factors that discourage senior doctors, in particular, from staying on as they approach retirement age. I suggest to the Minister that similarly detailed work needs to be done to understand the precise factors that are leading more junior staff at earlier stages in their career to leave the profession. Similar attention must be paid to resolving those specific issues if we are to address the retention problem.

One way we can motivate staff to stay on is through continuous professional development and retraining into more highly skilled roles, yet training opportunities can be constrained by the capacity of those delivering it. Can the Minister assure us that training opportunities will be provided for existing staff as well as new staff, so that we do not end up holding back Peter in order to train Paul? It will be net negative if we lose staff from the existing workforce through missed training opportunities as we bring in new staff. More generally, is there an understanding of how we are going to build up that capacity for training existing and new staff?

When I was younger, I had a teacher who would often write on my essays, “Okay as far as it goes”. This would annoy me, but with the benefit of wisdom and age I have to concede that it was often fair and accurate. Today, we might say that this plan, into which I know a huge amount of work has gone, is okay as far as it goes. We can be confident that it will really make a difference only if it is delivered in full, and in particular if there is a sister plan for the social care workforce and a real effort made on staff retention. I hope the Minister will comment on some of those aspects.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)]

I thank noble Lords. Before I answer their points, and while I shall not repeat the Statement, it would be remiss of me not to repeat one thing, which is about Lord Kerslake’s passing. Lord Kerslake inducted me into government many years ago when I was a non-exec director at the Ministry of Housing, as it was then, and I always found him a very wise head and a very kind man. I am sure that condolences go from all of us, and particularly from me.

I welcome the constructive responses from the opposite Benches. As we have said, a huge amount of work has gone into this plan from some 60 organisations, including royal colleges, and it is an NHS document. I must admit that while I will take the description from the noble Lord, Lord Allan, of “Okay as far as it goes”, I prefer the description of Amanda Prichard:

“This is a truly historic day for the NHS”.


On a personal note, I am very glad not to have to answer about how quickly it is coming any longer.

On the detailed comments, the noble Baroness, Lady Merron, said that this is a living document, with the two-year update, and that is a critical part. I agree with her that this is going to be effective only if it is a live document that we continue to review, amend and improve as time goes on. On the quality management of staff, this comes to the point about retention. There is no silver bullet, as we know. I liken it to the approach we see in the cycling, in the Tour de France, with Team Sky: there are lots of little things that you have to do and it is the collective effect of putting those things together which really makes the difference.

Clearly, pay is an important element of that; the point of view of the pay review body is clearly going to be very important; clearly, pensions are a big move; clearly, professional development is a big part of it, not just for new staff but absolutely for existing staff as well. It is also about the conditions that people work in; it is not just the culture and leadership but the place they work in as well. That is why I am pleased that the capital parts of this are seen as very important in driving the right culture and environment that people want to work in: these are key to retention and driving productivity. The new hospital programme is a very important part of that, and so is the capital programme generally.

Equally, technology is a key part of this, as mentioned before, and that includes front-line staff. Just on Friday, I was at Chelsea and Westminster, where they showed me at first hand how they found the databases they were using really helpful, with basic patient tracking, making sure they were following them through the whole care pathway and managing their whole journey, so to speak. They were using it and enjoying it, if that is the right word, and that was key.

The point about NHS management and leadership is very important; this plan looks at the medical side, but we all know that leadership is so important for the effectiveness of hospitals and a key part of this.

The noble Baroness mentioned the focus on hospitals. Clearly, hospitals are a very important part of this, but underlying that is a key shift towards primary care and prevention. If you delve into the details of the numbers, you will see that the level of people who need to be trained for primary care is going up and that they are becoming a bigger proportion of the workforce. I think we all agree that that should be the direction of travel. To deliver that, we will need to look at the capital estate behind this and make sure that we have the GP surgeries and everything else in the right places.

I turn to social care. The increase in medically trained people can only be a good thing for social care and the sector as a whole. However, social care is not included here. It is difficult. We can make an NHS plan because we are the employer behind the NHS; whereas there are hundreds, if not thousands, of different employers in social care so it is not for us to make that plan. However, it is for us to make sure that we increase the supply of medically trained people, as set out in this plan. We know how important international workers are to that; we recognise that and the importance of visas. Notwithstanding that, the value of this plan is that, eventually, it will reduce our dependence on the need to recruit internationally. We will see it go from about 25% of recruitment, as currently, to about 10% because we are increasing the supply base and the pool of people who can do that, rather than making a change on the visa front.

As ever, I have tried to cover most of the points raised in the time available. I will follow up in writing on the rest, but I conclude by welcoming this report.