NHS Long-term Workforce Plan
(9 months, 4 weeks ago)
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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.
Lord Young of Cookham (Con)
My Lords, in welcoming the report, I press my noble friend on a very interesting suggestion on page 79, where the Government propose a “tie-in period” to
“encourage dentists to spend a minimum proportion of their time delivering NHS care”.
There are a number of professions trained at public expense that are in short supply, including police, doctors and teachers. Why have dentists been selected? Is it proposed to broaden this policy to other areas trained at public expense that are in short supply?
Lord Markham (Con)
I thank my noble friend. Dentists were pointed out in particular because so many of them go on to work not in the NHS but in private care settings. It is out for consultation, but I think that was the thinking behind it. For instance, even after five years, 93% of doctors are still registered and working in the health service; that is a lot lower in the dentist space. We are putting investment into that group and it is clearly perfectly reasonable to expect a return on that by a certain time.
Lord Watts (Lab)
My Lords, the Minister has set out the aims and objectives of the plan, which we all welcome, but does he understand that, unless we fix the care system at the same time, this plan is bound to fail? It could make it even worse, with staff moving from the NHS and away from care services. How will joined-up government address the problem of under- recruitment and low morale in the care service, which will make this plan either succeed or fail?
Lord Markham (Con)
I would like to think, as I mentioned before, that increasing the supply and training of the whole medical profession would help the whole sector. This is quite close to my heart; as I have mentioned before, my mum became a nurse later on in life and went through an apprentice-type route, for want of a better phrase. Having different entry points is a very positive thing. I sincerely hope that people going into a social care environment will see that as a building block to onward career progression and that it will set them up to take further qualifications later on in life, if they wish, in the nursing profession. We are looking to expand the whole sector, and the general belief is that that will benefit both social care and the NHS.
The Deputy Speaker (Baroness McIntosh of Hudnall) (Lab)
My Lords, the noble Baroness, Lady Brinton, is contributing remotely.
Baroness Brinton (LD) [V]
My Lords, while this NHS plan is welcome, can the Minister say whether this Government will undertake to commit to the plan and, crucially, to its funding and not change the number of education and training places, as happened last year and in too many previous years, causing chaos in planning for doctors, nurses and allied healthcare professionals? On hospital training places for junior doctors after they have finished their medical school courses, last year 790 medical graduates could not begin their junior doctor in-hospital training because the NHS did not have enough placements. Given that university medical school places are already capped and highly competitive, this is a complete waste of newly qualified medical graduates.
Lord Markham (Con)
It is absolutely a pipeline; some people might say, “Why are you not doing more earlier in this plan?”, but, as the noble Baroness says, there is no point training a lot of people at the university end if you do not have junior doctor places later in the system. That is why we are trying to get a sensible ramp-up so that we can build capacity into those places, recognising the point that the noble Baroness makes. On the numbers in the plan, we have set down £2.4 billion for the first five years of training and development, but the point about it being a live plan is that we will update it every two years. Given the data—this is an NHS document, not a Department of Health one—I would expect those numbers to change, as I would be amazed if we got it spot on first time. The whole point about making this an NHS living document that we can use and which updates is that we can all stick to the plan.
The Lord Bishop of Exeter
My Lords, we on these Benches very much welcome this workforce plan, in particular the expansion of places for training with a range of clinicians and the shift of gaze towards community care and prevention. Our anxiety very much mirrors that of the noble Baroness, Lady Merron, and the noble Lord, Lord Allan of Hallam. We notice that page 23 of the report says:
“This Plan is predicated on access to social care services remaining broadly in line with current levels or improving”.
That is a jolly big assumption given that the Care Quality Commission report tells us that there are vacancies of 10.7% in adult social care and of 13.2% in the home care services. Without an equivalent plan for social care, in our view this admirable workforce plan is unsustainable, so will His Majesty’s Government publish an equivalent plan for social care?
Lord Markham (Con)
As I mentioned previously, the NHS plan is something that we or the NHS can publish, being the employer. With there being hundreds, if not thousands, of employers in social care, it is clearly a different situation. What we can do is make sure that we put the investment into the sector, so that there is pull through in the number of places. Over the next few years, we are looking at an increase of up to £7 billion, which is about 20%. We know that, of that £7 billion, around 65% to 70% flows through to staffing and wages. We are seeing a massive investment on our side, which we are looking to lots of employers to fulfil. By increasing the number of medically trained people, we will be increasing the supply base to fulfil that demand.
Baroness Harding of Winscombe (Con)
My Lords, I too thank and commend my noble friend the Minister, the Secretary of State and the leadership of the NHS for producing an extremely good plan. It is historic, not because it is the first time such a plan has been written but because it is the first time in 20 years such a plan has been published. The Minister has commented a couple of times that this is a living plan—one that will be updated at least every two years. Could he confirm that those updates will be published every two years, and that this House will be able to debate and discuss them?
Lord Markham (Con)
That is absolutely my understanding. For it to be a living document, people clearly need to have input and to be able to debate it in exactly the way we are doing here today.
Lord Hunt of Kings Heath (Lab)
My Lords, I remind the House of my membership of the GMC Council. The GMC has warmly welcomed the plan and its role in the expansion of medical education, the development of physician and anaesthesia associates, and the apprenticeship programme. I want to follow on from the point made by the noble Baroness, Lady Brinton. The key point the GMC has made is that it is absolutely essential that there are sufficient clinical and educational supervisors, particularly for the F1 grade—newly qualified doctors going into postgraduate training. NHS trusts will have to release more of their doctors to provide this. Is the department in touch with and talking to the chief executives of NHS trusts to ensure that, as the pipeline develops, there will be sufficient clinical supervision? This is essential in order to get the quality of doctors that we need.
Lord Markham (Con)
The noble Lord is correct that it is essential. I emphasise that this is an NHS document, and the whole point is that it does not look to go “zoom” on recruitment. There is absolutely the understanding that this is a pipeline that has to be built brick by brick. There is no point front-loading the number of university places if, as the noble Lord mentions, there is no follow-up behind it in clinicians. The plan has been developed from the bottom up, including with clinicians and the trusts. There is an understanding that they need to build their own part of the pipeline towards this as well.
Lord Jackson of Peterborough (Con)
I welcome this ambitious and comprehensive workforce plan and I concur with other noble Lords on the issue of social care. On the specific issue of medical school places, while I strongly welcome and commend the Government for responding to the campaign of many people—including Policy Exchange and its excellent Double Vision report, published earlier this year—my concern is the waste of resources and the talents of those thousands of A-level students who do not get university places to study medicine. While I welcome the focus on degree apprenticeships and the regionalisation of medical education, is there any chance that we could speed up the process? Another eight years to double the number of medical places is an awfully long time—it is almost the equivalent of two Parliaments.
Lord Markham (Con)
As for the A-level point and those people not being able to go on to universities, that is what the different routes are about. The different pathways that we are talking about include nursing associate training places, which we want to see increased to 10,000, and similarly with physician associates. While we all understand that having a university education is a fantastic medical grounding, there are many other ways to get there. I am sure we all have very good examples of fantastic clinicians who did not have a degree.
Lord Harris of Haringey (Lab)
I refer to my interest as chair of the General Dental Council. I welcome not only the whole document but the specific commitment within it to increase the number of dental training places by 40% by the beginning of the next decade. Does the Minister accept that simply increasing the number of dentists will not solve the problems of NHS dentistry if dentists decide that it is more lucrative for them to practise privately rather than through the NHS? This is only part of the process. If the solution to dealing with the problems of NHS dentistry is to essentially create a tied class of dentists who have trained and are therefore expected to work in the NHS, I am not sure that this will be sufficient.
I also raise a more general point which is nothing to do with dentistry specifically. Could the Minister tell the House what proportion in any one year of the number of people entering the workforce are expected to go into the NHS? My calculation suggests that they are expecting the figure to go up from 10% of those entering the workforce to 15%. What will incentivise that, and will it be addressed through the various pay processes that we have already referred to?
Lord Markham (Con)
I thank the noble Lord for the work he does as chair of the GDC. He will know that this is something that is quite close to my heart, given that my better half is a dentist. I completely agree that it is about far more than just the training places. I think the House has heard me discuss this before, but if we are serious about dentists who have been in practice for 10 years setting up their own clinic, maybe in an NHS Digital desert, we must give them guidance and support, as it is quite an ask to do that. We plan to produce and publish a dental plan in the not-too-distant future, in which I hope and trust that a lot of these points will be covered.
The noble Lord is correct; I do not know the exact maths behind it, but we spend roughly 12% of our economy on the health sector and so it is not surprising that roughly that number would be expected to go into the NHS workforce. In some ways, that shows the magnitude of everything we are talking about today. Probably one in eight of all people leaving school will end up in this sector—that really is a number worth thinking about and pondering over. As we all agree, it shows why this plan is timely and why it must be a living document that is continually adjusted as we go forward.
Lord Young of Norwood Green (Lab)
My Lords, I welcome this historic document. I concur with some of the concerns expressed by my noble friend on the Front Bench. Nevertheless, I believe it to be very significant. It addresses many important areas, such as apprenticeships and training, all of which I welcome. I could carp and say that we will check against delivery, and of course we need to. I hope we will have a proper debate on this plan at some stage, and I would welcome an assurance from the Minister on this. It merits a much longer debate; it is probably one of the most important issues that this House has discussed.
I am interested in dentistry because I recently visited my local dentist—a man of principle who converted a private practice into an NHS practice. I always get him to do my teeth, and he cleaned and scraped them and did all the necessary things, and he then took X-rays. I went to the desk to pay and the charge was £28.50— I could not get a plumber to come out for those prices.
If you do not reward NHS dentists—that dentist’s son and daughter are both practising dentists—they will inevitably go into private practice. If we are serious —I believe we are—about doing something, of course we have to look at the charges. I do not want to end on a negative note. I agree with those who have said that this is one of the most important issues that this House has discussed in a long time, and I welcome the Government’s actions.
Lord Markham (Con)
I thank the noble Lord. He is quite right to say that we need to check against delivery and he is quite right to hold us to account on that. Personally, I am happy to commit whatever time we need to debate this because I completely agree on how important it is. As I say, it is quite sobering when you think about the figures: as we said, we expect one in eight school leavers to go and work in this sector, so we almost cannot spend too much time on that.
As I say, the dental plan will be published shortly, and making sure that the balance is right, and that it is seen as an attractive option to be an NHS dentist versus working in the private sector, is absolutely an important part of that as well.
Baroness Watkins of Tavistock (CB)
My Lords, I very much welcome this plan and in particular the fact that we will start to deliver more homegrown healthcare workers; in fact, the WHO has applauded us for these moves because there is such an international shortage, not because overseas workers are not welcome here.
I want to ask one question. I very much support the concept of apprenticeships, but professional workers on registers, be that nursing, medicine, physiotherapy or paramedicine, expect apprenticeships to be degree-level apprenticeships, accepting that the entire workforce will not be graduates but that registered clinicians should be. Can the Minister please clarify that issue?
Lord Markham (Con)
I thank the noble Baroness. The whole idea of the apprenticeship is that the standard that you are training to is absolutely the same, albeit obviously you are getting there via a different route. However, as regards the capability, training and knowledge of that person, clearly, whichever route they have come from, they need to be at that same required level. That is why the royal colleges have been such an important part in the development of this whole plan.