Well, this has been another fascinating debate, and I welcome the contributions from all noble Lords speaking from many years of experience, including former chief executives of the National Health Service and former Health Ministers, medical experts and practitioners. I am grateful to the many noble Lords who have laid amendments in this group; there clearly is a strength of feeling, not only in this Chamber but in the other place. To cut a long story short, this will clearly require more discussion.
However, I am duty bound to give the Government’s perspective on this. We have committed to publishing a plan for elective recovery and to introduce further reforms to improve recruitment and support our social care workforce, as set out in the White Paper, People at the Heart of Care: Adult Social Care Reform. I take the point of the noble Lord, Lord Stevens, that he is aware of many expectations that have passed, and I hope that this time we surprise him. We are also developing a comprehensive national plan for supporting and enabling integration between health, social care and other services that support people’s health and well-being.
The monthly workforce statistics for October 2021 show there are record numbers of staff working in the NHS, with over 1.2 million full-time equivalent staff, which is about 1.3 million in headcount. But I am also aware of the point of noble Lord, Lord Warner, that it should not just be about the number of people working—it is about much more than numbers and quantity; it is about quality and opportunities. We are also committed to delivering 50,000 more nurses and putting the NHS on a trajectory towards a sustainable long-term future. We want to meet our manifesto commitment to improve retention in nursing and support return to practice, and to invest in and diversify our training pipeline, but also, as many Lords have said, to ethically recruit internationally.
On that, I want to make two points. The first is this. When I had a similar conversation with the Kenyan Health Minister and expressed the concern we had about taking nurses who could work in that country, the Minister was quite clear that they actually train more nurses than they have capacity for in their country—they see this as a way to earn revenue. There have been many studies on how remittances are a much more powerful way of helping countries, rather than government-to-government aid. With that in mind, we recruit ethically, and we have conversations.
The second point is also from my own experience. I was on a delegation to Uganda a few years ago and I remember speaking to a local about the issue of the brain drain and our concerns. We were talking about immigration, and he said, “You do realise, though, it is all very well for you to patronise me and say that I should stay in this country, but sometimes the opportunities are not here for me in this country. You talk about a brain drain; I see my brain in a drain”.
Sometimes we have to look at the issues of individuals who are concerned that they do not have opportunities in their countries, even if the numbers dictate otherwise. Having said all that, we are committed to the WHO ethical guidelines, but I also think that we should be aware. Look at the way that, post war, the people of the Commonwealth came and helped to save our public services. I hope we are not going to use this as an excuse to keep people out, though I understand the concern that we have to make sure that we recruit ethically internationally.
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On Amendments 170, 171 and 173, the department has commissioned HEE to work with partners to develop a robust long-term strategic framework for the health and social care workforce for the next 15 years, which for the first time includes regulated professionals working in adult social care such as nurses and occupational therapists. The report provided for in Clause 35 will also increase the transparency and accountability of the workforce planning process. However, this amendment would require an independently verified report to be published every two years with the assistance of HEE and NHS England. Given what we have heard tonight about some of the long lead times for training of health professionals, there is a concern that publication in a two-year cycle could be seen as too rapid given the long lead times for many health professionals.
However, one of the things to be welcomed is the different pathways into nursing. There are nursing apprenticeships, and there are also different pathways into becoming a doctor. If you have been a nurse and you have worked a certain number of hours, you can train to become a doctor. That shows that we are being innovative with regard to the different pathways into different jobs in the health and care sector.
Last year, we announced our intention to formally merge NHS England with HEE. The transfer of HEE’s functions to NHS England is subject to parliamentary approval. If approved, this will help ensure that service, workforce and finance planning are integrated in one place at a national and local level.
The Government share the wish to see safe patient care. Safe staffing remains the responsibility of local clinical and other leaders, supported by guidance and regulated by the CQC. Good quality care is influenced by a far greater range of issues than how many of each particular staff group are on any particular shift, but it is clearly important, which is why the Government are committed to continuing to grow the workforce.
On applying the lessons learned from formal reviews and commissions concerning safety incidents, in the last decade the Government have introduced significant measures to support the NHS to learn from things that go wrong, to reduce patient harm and to improve the response to harmed patients. These include a regulated duty of candour, protections for whistleblowers, the Healthcare Safety Investigation Branch, the first-ever NHS patient safety strategy, medical examiners implemented across the NHS and legislation to establish a patient safety commissioner.
On Amendments 83 and 86 from the noble Baroness, Lady Walmsley, responsibility for safe staffing rests with individual employers, and it would be inappropriate to confer such a duty on ICBs instead. Reaching the right staffing 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, as well as considering local issues specific to individual employers. There need to be safeguards to ensure that they deliver this responsibility effectively and that robust arrangements are already in place.
Appropriate staffing levels are already a core element of the CQC registration regime for health and social care providers, and providers are required by the CQC to deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff. Staff must also receive support, training, professional development, supervision and appraisals as necessary. In this work, employers are supported by guidelines from the National Quality Board and NICE which are based on the best available clinical evidence and are designed to ensure patient safety.
Amendment 83 seeks to amend new Section 14Z41—“Duty to promote education and training”—in order to consider safe staffing. I highlight to the noble Baroness that Health Education England already has a statutory duty to exercise its functions with a view to ensuring that a sufficient number of persons with the skills and training to work as healthcare workers for the purposes of the health service is available to do so throughout England, as in Section 98 of the Care Act 2014. To place additional obligations on ICBs in relation to the workforce is at this stage seen as unnecessary.
Turning to Amendment 172, the Clause 35 report is not intended to produce assessments of supply and demand of staff itself, but rather to describe the system in place for assessing and meeting those needs. However, in relation to the coverage of non-regulated staff in the Clause 35 explanatory report, currently, Clause 35 does not seek to make a distinction between the regulated and non-regulated elements of the workforce. Clause 35 requires that the Secretary of State’s report cover the
“workforce needs of the health service.”
Our intention, therefore, is to include a description of the systems in place that cover the non-regulated elements of the health workforce, where appropriate.
The noble Baroness also raises the issue of integrated workforce planning across NHS and non-NHS employers. I hope to reassure her that we share her view of the importance of this issue and that work is under way on it. Section 1F(1) of the NHS Act 2006 places a duty on the Secretary of State for Health
“to secure that there is an effective system for the planning and delivery of education and training to persons who are employed, or who are considering becoming employed, in an activity which involves or is connected with the provision of services as part of the health service in England.”
This duty is delegated to Health Education England under Section 97 of the Care Act 2014.
In discharging this function, HEE takes account of requirements of employers of health and care staff beyond the NHS in England, including independent
practice, social enterprises and the voluntary sector, because to ensure that the needs of the NHS are met, the needs of other sectors with which it works must be taken into account. We heard the noble Lord, Lord Mawson, speak so eloquently about the work of social enterprises and the voluntary sector.
The amendment also calls for the assessment of workforce demand to include demand across Scotland, Wales and Northern Ireland. Although we recognise that workforces across the health services in the UK are interlinked, this amendment to formally report and assess demand is unnecessary and represents an additional burden for the devolved Governments, who have their own systems in place. Where appropriate, the department and HEE already work collaboratively with the devolved Governments and their arms-length bodies in relation to workforce planning and supply, without the need for formal legislative requirements. We must continually stress to the devolved Administrations that we recognise the constitutional settlements.
For example, the UK Foundation Programme office, which facilitates the operation and continuing development of the foundation programme for doctors, is jointly funded and governed by HEE and the devolved Governments. In addition, there is a regular dialogue, which I have alluded to previously. Also, many of the healthcare professional regulators, including the GMC, NMC and HCPC, operate on a UK-wide basis to enable doctors, nurses, midwives and other health professionals—so eloquently referred to by the noble Lord, Lord Bradley, and others—to work across the UK. As part of their regulatory activities, they publish data on how many registrants are on their register and therefore available for work in the UK. This data is available for use for workforce planning across the UK.
Turning to Amendment 174, we recognise the importance of ensuring that staff across the NHS and social care are properly paid—an issue that noble Lords have rightly raised a number of times. However, we are not sure that an annual report by the Secretary of State is the right approach. There is a well-established process in the NHS for those on national contracts. Individual NHS organisations determine what roles are required and where these fit on the agreed pay structures within national contracts. These national contracts set out progression arrangements where applicable. For those on entry level pay points, we do not expect NHS organisations to report to us on the profile of their workforce.
In addition, the vast majority of adult social care workers are employed by private sector providers, who ultimately set their pay, independent of central government. An issue with using these private sector providers is that often, they cross-subsidise taxpayer-funded patients from their private patients. But local authorities do work with care providers to determine a fair rate of pay based on local market conditions. Part of the increase in funding that we announced was to address that issue, to ensure that care homes taking taxpayer-funded patients are paid a fair rate. The Government would not expect any private sector organisations to undertake additional reporting to government on pay rates, the rates of progression
available and the profile of the workforce at different pay points. We see that as an unfair additional burden on social care providers.
Amendment 146 places a requirement on ICBs to report on workforce requirements. We agree that ICBs will have a critical role to play in growing, developing, retaining and supporting the entire health and care workforce locally. To support them in fulfilling this role, in 2021, NHS England published—I use this word advisedly—draft guidance on the ICS people function.
ICBs will have specific responsibilities for delivering against the themes and actions set out in the NHS people plan, as well as the functions outlined in guidance. These functions include growing the workforce for the future and enabling adequate workforce supply, through strategic planning and collaboration on recruitment and retention across the system. NHS England will have a role in supporting this. It has also set out an expectation that ICBs will develop collaborative workforce plans based on population health needs and take an integrated approach to planning across workforce, finance and activity. We expect this approach to tie into their strategic planning cycle. The guidance also asks ICBs to work with regional and national workforce teams to support aggregated workforce planning and to inform on priorities.
On Amendment 214, most, if not all, ICSs already currently have an ICS people board or equivalent for overseeing delivery of these plans. The draft ICS people function guidance sets the expectation that these will continue to be in place, including as part of preparatory arrangements for formal establishment.
As previously discussed, the Bill intentionally sets a floor, not a ceiling, for ICB membership. This is one of the issues we will have to continue to discuss, given all the amendments noble Lords have submitted on mandatory places on integrated care boards; this is clearly going to mean discussions in the round. The ICS design framework, published in June 2021, sets out the proposed requirement for ICBs to have executive board roles that include, as a minimum, a chief finance officer, a medical director and an executive chief nurse. NHS England and NHS Improvement’s guidance on effective clinical and care professional leadership, published in September 2021, aims to support future ICBs in ensuring appropriate involvement of multi-professional clinical and care leadership in decision-making within the ICB area.
Having said all this, I see that the number of amendments that have been tabled reflects the strength of feeling in this House and the other place on workforce issues and workforce planning. I hope I have been able to assure the Committee of the department’s extensive, ongoing work to support the entire health and social care workforce.