Health Education England (Transfer of Functions, Abolition and Transitional Provisions) Regulations 2023

Lord Scriven Excerpts

Tuesday 21st March 2023 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interest as a relatively new non-executive director of NHS England, appointed together with two expert doctors to give clinical input to the board and tackle the issues that have just been discussed. However, I want to put on record that I think Health Education England has been a success and has set up sound processes that have enabled a good estimation of the workforce needed for the next 15 years.

The workforce plan is in draft and is being considered by the Government, but I want to underline the fact that, without sufficient funding, it will not achieve what everybody wants it to achieve. I believe that making it mainstream in NHS England should mean that, working with the ICBs, we have a sound approach for the future. I am aware that the two previous speakers will be able to hold NHS England to account on whether we get it right or not. I felt that I should be here this afternoon to say that I think it will work, but only because of the sound foundation that NHS Education has left behind.

I also want to echo one concern: that we have to calculate social care needs within the workforce development plan, in particular the needs of leaders of teams in social care, who are often nurses or allied health professionals such as physiotherapists. On that note, I will sit down; I wanted to express my current understanding of the situation.

[Lord Scriven (LD)]

My Lords, I wish to add briefly to the very useful and interesting debate that the noble Baroness, Lady Merron, has stimulated with her amendment. In so doing, I point out my interest as a vice-president of the Local Government Association.

I support the general direction of the merger. I can see why HR functions need to be streamlined together rather than partly devolved and partly in NHS England. The Minister quite rightly pointed out his business background; I have a background in organisational development and public sector reform, not necessarily in the UK but in Africa and south-east Asia. One of the key failures in the public sector when these organisational structures happen, predominantly for cost reduction reasons—it is always said by those leading them that cost reduction is not the reason, but it is important—is that there are no measurements for success in three, five, 10 and 15 years. Without that, you get a structure without understanding how the structure will deliver exactly what is needed.

So, what are the measurements for success in three, five, 10 and 15 years? Without those, everyone can say there is a target, but no one knows what that target, or bull’s-eye, really is. What are the clear measurements within three, five, 10 and 15 years? If they are not there, how do we know what success looks like based on what the merger was about in the first place? That is really important.

The other part of this is that you can have all the training and numbers you like for the workforce, but if the support, conditions and culture are not right, people will leave, as they are doing now in parts of the NHS. In certain specialties, you cannot get a doctor for money, no matter how much you offer. Part of that is about working conditions, culture and support. How does this merger deal not just with numbers and education but more holistically with the culture and support? For example, in many trusts, junior doctors cannot even get a meal in the evening. You can have all the numbers you want in terms of training, but if people decide not to work because of the conditions, how does that help holistically? How do we ensure we have not just the training and numbers but the culture and support within organisations so that people decide to go and work there?

My final question is simple. All noble Lords who have spoken have mentioned social care. As I said, my question is simple: how does this plan link with a plan for the social care workforce? What problems are envisaged and what mitigation has been put in place to ensure, first, that the two plans work in tandem and, eventually, as a long-term aim —I have heard Ministers talk about this—that staff will be able to move across the organisational divide? How will the links be there? What mitigation is being put in against the risks for a social care plan and a healthcare plan? This is important because people who start with a health problem then require social care to make as good and independent a life as possible. It is important that, when the Government start on one plan, they understand the linkage with the other and the mitigations needed. I hope that the Minister can put the mitigations in place.

As I said, in general, I understand the reasons for this but there are serious questions that the Minister needs to answer to ensure the maximum impact from this merger.

[Lord Markham (Con)]

I thank noble Lords for their contributions to today’s debate. As ever, I will attempt to answer the questions as best I can, and I will come back in writing with the details.

First, on when the workforce plan will be published, forgive me for this answer but I cannot resist it. I looked on the HEE website and it will be delivered “at the right time and in the right place”. I could not resist that one. I think the term I am allowed to use is “shortly”, which is different from “soon”, but I will let noble Lords decide. Seriously, however, there is a very detailed plan. While I acknowledge that there are concerns about delays and this being “Treasury-fied”, at the same time, serious questions have been raised, as we would expect. This is leading to a lot more thinking, which is the right thing to happen, provided we come out with the right answer. I hope noble Lords understand that work is going on to ensure deliverability.

I will try to answer the many questions asked, particularly on what the measures of success will be, as raised by the noble Lord, Lord Scriven. From my point of view—it may be personal—we are publishing the workforce plan and the measure of success will be how well this body performs against that. It will not be down to that body alone; it is part of the newly merged entity. As the noble Lord, Lord Scriven, said, it is about recruitment, training and retention.

A key issue, as I know from being tangentially involved in some of the conversations with unions in the last few weeks, is a real recognition on our part that pay is a core issue, but so are things such as hot meals, rest areas for staff and parking. Some of those issues are important “health factors”, if you will excuse the pun, and we are very alive to them.

Turning to the questions raised by the noble Baroness, Lady Merron, and the noble Lords, Lord Allan and Lord Scriven, as I say, it is about looking at savings across the piece. As noble Lords will know, we are talking about quite a considerable structure. The average trust is run by 300 or 400 admin staff; an ICB has 700 staff; a region has 650 to 700 staff; the NHS itself, at the centre, has 4,000 staff; and the Department of Health and Social Care accounts for another 3,500 to 4,000 staff. I think we would all agree that layer upon layer of management is not good, from not only a cost and efficiency point of view but a management point of view. We all talk about our various backgrounds, and speaking from mine, the fewer layers you have between the so-called management and the front line, the better. That is the wider picture of what we are trying to do here.

[Lord Scriven (LD)]

I totally agree. I think Tesco, for example, has four levels of management between the customer and the chief executive. But I hope the Minister understands that, regardless of layers—this may not make me popular outside this place—the NHS is one of the most effective health services in western healthcare in terms of management costs. I hope the Minister does not take the populist view that having a go at the managers suddenly makes savings. We have to get the balance right. On comparators, the NHS is significantly well placed in the western world in terms of its cost ratio of managers to patient care. I hope the Minister will accept that.

[Lord Markham (Con)]

The noble Lord is right: it is about the effectiveness of the layers. I come at this from the view, “How do we make this most effective?” That is the major gain to be won from all this.

The noble Baroness is right to bring up the issue concerning the Secondary Legislation Scrutiny Committee. I have spoken to all the staff in the DHSC about it, and I have given assurances to the House on the importance we attach to it. I am meeting the Leaders of both Houses tomorrow to discuss how we are working to make improvements in this space. Hopefully, we are making progress.

I thank the noble Baroness, Lady Watkins, for her contribution. It is fantastic to have her on the board, given her experience. Several noble Lords asked about the social care element. As we know, the situation is slightly different because most people in the social care space are employed by third-party organisations. There will not be a direct read across, but the Minister will be announcing shortly the next version of People at the Heart of Care, which aims to address a number of issues. It is probably best to wait for that, and we can take it from there.

I have tried to cover as many of the issues raised as possible, and I am quite happy to follow up in writing any I have missed. Reassurance was sought regarding current training budgets, pointing out that, while we want to make savings where possible, we need to know they are being made in the right place. A separate board structure is being set up within the organisation to make sure that such matters are separately scrutinised and not lost within the overall picture, because it is understood how vital that is. These are all elements I will try to cover more completely in a written response.

[Lord Scriven (LD)]

That is a helpful answer. To be clear, you can have a separate board, but if the budget is not ring-fenced, all that they are scrutinising is a smaller budget. I think the question that was asked—although maybe not specifically—was, will the training budgets be ring-fenced and will the board therefore be looking after a ring-fenced budget?

[Lord Markham (Con)]

I think that is probably one element I need to come back to the noble Lord on in writing.

As I said, I will try to follow up the questions in detail. I welcome the contributions of various noble Lords and their understanding of what we are trying to do here. I understand the arguments, as an ex-management consultant, regarding centralisation versus decentralisation and how they go in and out of fashion. This is a slightly different case because it is about bringing a core function in house. To me, that is the key change and the key thing we will be seeking to measure. As well as setting out clinical needs, the key role of the NHS at its centre is making sure that it is recruiting, training and retaining talent to meet the workforce plan needs. On that note, I thank noble Lords for their contributions and hope that my follow-up answers any questions that I missed.