Operational Productivity in NHS Providers

Karin Smyth Excerpts

Wednesday 1st July 2015 Westminster Hall

[Dr Offord]

I certainly do agree with that point, and I hope to elaborate further on that. I also wish to touch on the use of bank nurses, or bank employees, who periodically work for parts of the NHS. I agree that for patient care it would be best to have full-time permanent staff who not only know the patients and the hospitals, but know the other employees they work with on a day-to-day basis.

Most worryingly, Lord Carter identified the fact that, in some of the 22 hospitals he surveyed, bank nurses are remunerated at a level that does not discourage them from remaining with, or moving to, agencies. I looked at the website of one of the trusts that took part in the review by Lord Carter and was surprised to see the range and number of bank employees—including, ironically, the position of the e-roster co-ordinator. I will not name that particular trust, as this debate is not a “name and shame” exercise, but I raise it to illustrate the point, because if such a role is vacant, what hope can there be to ensure that other clinical positions are staffed suitably?

The e-roster co-ordinator is in the best position to monitor employment and identify irregularities in work patterns to prevent fraudulent practices. The majority of people who work for the NHS are honest, but there are a minority who seek to defraud its resources. I want to highlight the types of fraud that occur. Such fraud involves staff and professionals who claim money for services not provided or more money than they are entitled to, or who divert funds to themselves. It can also involve external organisations that provide false or misleading information, including invoices, to claim money they are not entitled to. Some of these frauds can be fairly low value, but they can often cost the NHS hundreds of thousands of pounds.

One example is Michael Botham, a hospital worker in Stoke-on-Trent who claimed nearly £20,000 for shifts he did not work. He applied for work via a recruitment agency, AMG Nursing and Care Services, in October 2007. He was then assigned as an unqualified healthcare worker to Bucknall hospital in Stoke-on-Trent, where he worked in the complex needs ward. Most worryingly, it took a ward manager to identify an overspend and to report their suspicions about Botham to the trust’s local counter-fraud specialist team. When the team analysed his timesheets, they revealed that he had submitted false claims for work from 1 January to 26 July 2009, complete with forged authorisation. In fact, he had worked only one shift during that period.

Botham also claimed payment for four shifts at Bradwell hospital, part of the same trust, in January 2009. Again, he had not worked those shifts and the authorising signatures were also false. In total, the trust overpaid £19,362 as a result of his false claims to the agency, which invoiced the trust in good faith on a weekly basis, but subsequently, to its credit, offered to pay back its fees of £3,956.50. This is a clear case of an individual deciding to defraud the NHS, but what is concerning is that the problem emerged only as a result of the scrutiny of another member of staff whose role was not to look for fraud.

[Karin Smyth (Bristol South) (Lab)]

I worked for a clinical commissioning group in Bristol. Does the hon. Gentleman accept that one reason why that would have happened is that all members of NHS staff have to undergo mandatory and statutory training to recognise and counter fraud?

[Dr Offord]

I do, but I am saying that this should have been picked up by an individual with a strategic, holistic approach to staffing and staffing budgets, rather than leaving it to one individual on the ward who realised there was a problem with the budgets. There are processes in place to ensure that fraud does not happen, and I would like all hospital trusts to introduce such processes. In his report, Lord Carter highlights a case where one provider identified 20 cases of counter-fraud when they reviewed and strengthened their sickness and annual reporting leave. That prompts the question of why such abuses continue to be left unchecked.

There is another case of fraud that I want to highlight, which has been judged more harshly, although it can be argued that it is certainly not as deceptive because the individual actually undertook the work. Simon Olufemi Ajani was sentenced to 12 months’ imprisonment following a fraud investigation by NHS Protect after he had produced a false passport and certificate of entitlement to the right of abode in the UK. That enabled him to obtain work with patients at East London NHS Foundation Trust, South London and Maudsley NHS Foundation Trust, and other London trusts through NHS Professionals, the agency that supplies temporary staff to the NHS. His fraud was first uncovered through a data-matching exercise that highlighted inconsistencies between UK Border Agency records and NHS payroll records.

The difference between those two cases is that Ajani worked the hours that he was paid for, even though he was not entitled to be employed in this country, while Botham was just a crook stealing money directly from the NHS and patient care. These examples lead me to ask the Minister about the employment of those from outside the EU, an issue I have discussed recently with my constituents, as I mentioned. There is some criticism about the use of foreign doctors in the NHS, and some people consider that these jobs have been taken out of the reach of British people. However, we all know that the NHS does not have the numbers of doctors and nurses that it needs and there is not the capacity within the population of the United Kingdom to provide them. That is why some agency staff are required.

For some medical practitioners, however, remaining a locum is an alternative to having a permanent position. Some doctors are able to earn between £1,400 and £1,500 for a 12-hour shift, while the on-costs payable to agencies mean that hundreds of thousands of pounds a year are being charged to health trusts around the country for employment of temporary staff. One alternative to the costly system of locums could be the employment of a permanent doctor from overseas who could earn a salary of between £75,000 and £120,000. I need not ask the Minister whether he feels that this is better value for money than having a locum.

The NHS is an employer of those considered to have skills that are needed in this country, and a tier 2 visa allows “skilled workers” from outside the European economic area with a job offer to enter the UK. However, it has been established that the immigration health surcharge is levied against non-EU citizens. This requires every applicant and their dependents to pay not only their visa fees but a further £200 each year for up to three years. It strikes me as perverse that the very people needed to work in the NHS are being penalised by paying an additional amount that should perhaps be part of their terms and conditions of employment. Can the Minister explain in his summing up how the figure of £200 was reached and whether he feels that levying this tithe against NHS employees is counterproductive?

Lord Carter’s report goes on to identify opportunities in managing annual leave—what he terms the largest part of non-productive time. There are many ways in which NHS employers can ensure they manage staff leave. I am not going to stand here and say that the Minister should micro-manage the NHS in England, but even simple practices do not appear to be implemented in some NHS trusts. We all agree that, while the needs of patients must be considered when managing annual leave, people do need time off. Introducing a notice period of a month for leave requests of, say, more than three or four days would allow NHS managers the time to plan ahead, but that is not happening uniformly, thereby ensuring that agency staff are needed as an emergency measure.

Can the Minister therefore confirm that measures introduced by the Secretary of State to reduce agency locum spend will include a requirement for trusts to ensure that their employment practices and policies include such conditions as notice periods to book leave, that trusts consider employing e-roster co-ordinators and that trusts examine their employment policies so that they can compare themselves with their peers and undertake a skill mix review, the combination of which would reduce the need for spending on agency staff?

A fear raised with me by my constituents concerns the revalidation of full-time locum doctors. It is well known that locum doctors can experience a variety of challenges with revalidation, largely due to the peripatetic nature of their work, but annual appraisals are the backbone of revalidation and fundamental to demonstrating the fitness of medical professionals to practise. Revalidation should be carried out by the framework suppliers—the agencies that supply staff—but I have heard anecdotal reports that agencies do not revalidate, and it has been alleged that some health professionals are even practising outside their qualifications and skill range. Can the Minister tell us how the Department will ensure that the revalidation of all full-time locum medical professionals is carried out by the framework suppliers?

The final issue about the use of agency staff I want to raise is the use of master vendor contracts between health trusts and employment agencies. The use of this practice creates an opportunity for collusion within the employment industry to seek maximum financial gain through the use of exclusive contracts. While such contracts may be an easy option for the employer—in this case, the health trust—the agency can ask premium prices for a service that could be provided more cheaply if it were opened up to competition. Such a practice effectively introduces a closed shop and prevents smaller employment agencies from being able to enter the health market. Can the Minister advise us how the Department can ensure that the use of master vendors does not result in tacit collusion in the employment industry for exclusive contracts that cost the NHS more than it might pay for the services elsewhere?

In conclusion, this debate is not a negative criticism of employment agencies or the work of people in the NHS; in fact, it is the opposite. I congratulate the people who work in the NHS and I want to ensure that more people are employed in the NHS. I am framing this debate as an opportunity to assist the Government in ensuring that the resources needed by the NHS and identified by the Stevens review are made available. It is an opportunity to start the process by recognising where we can work smarter to ensure a better NHS for all and identify opportunities to achieve economies that do not undermine patient care, but in fact achieve the opposite, by ensuring the correct number of appropriately qualified staff in the NHS, working confidently, diligently and at a pace that ensures the best care for patients.

[Karin Smyth (Bristol South) (Lab)]

Thank you, Mr Pritchard, for calling me to speak.

I agree with the hon. Member for Hendon (Dr Offord) that of course there are always efficiencies to be made, and ways of considering how they can be made; NHS managers and staff, including clinical staff, spend a great deal of their time doing that. My intervention about counter-fraud was meant to suggest that that work becomes part of the way that people start thinking about their work as public servants. However, this debate needs to be widened out beyond the individual savings that have been mentioned. As the King’s Fund has said, the greatest savings achieved in the NHS since 1948 were made since 2010, largely through reductions to pay and central budgets, and some restructuring. Having said that, I am slightly sceptical about the savings that can be made through restructuring.

We need to move this debate on to a discussion about quality in its widest sense, because quality is an organising principle of the NHS; ultimately, quality will deliver greater savings and contribute towards the £22 billion target. It will also involve people much more in the management of their healthcare, so that we save money that is currently spent on public health interventions. We must also ensure that when people use the health service, they understand where savings can be made. If we were able to involve patients and others much more in that debate, we would find more good examples of what we have been discussing. There are some great examples from Bristol, particularly around environmental savings. There have been some fantastic projects to reduce consumption of energy, both at Universities Hospital Bristol NHS Foundation Trust, and at North Bristol NHS Trust. There is also the reskilling that takes place within the community services organisations, to make better use of the highly skilled community nurses and to help people with the flow in and out of hospital.

However, all these measures require the system to be stable and require some transitional support to allow the transformation to happen. At the moment, I am not sure that the NHS feels it has the support to make that happen, as individual examples that will not yield overall results are being picked out. I welcome this debate about productivity, but I hope that we can have a degree of political honesty about the scale of the challenge of the £22 billion cuts.

[Mr Jim Cunningham]

The hon. Member for Hendon (Dr Offord) talked about efficiency, which is one thing; productivity is something totally different. Productivity is what the individual produces, whereas efficiency is really about how the individual works. Does my hon. Frind agree?

[Karin Smyth]

I agree with my hon. Friend. It is the environment in which an individual works and is supported into work that helps to boost productivity. I think we would all agree that generally people want to be as productive in the service as they can be, and they are very cognisant of their role as public servants. As I say, I would like to see political honesty and discussion about the scale of the £22 billion cuts. It is hard to see where they will come from, regardless of pay restraint, cuts to services and major reconfigurations. Those changes may need to happen, but there needs to be honesty across all parties in the House to support their introduction.

There is wide-scale agreement about the problems that the NHS faces, beyond the items that the hon. Member for Hendon mentioned, but now that the election has passed it is time for us to consider the solutions that can be achieved to support staff in making that transformation, and in making the NHS highly productive, as well as one of the most efficient services in the world.

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[Andrew Gwynne (Denton and Reddish) (Lab)]

It is a pleasure to see you in the Chair, Mr Pritchard. I congratulate the hon. Member for Hendon (Dr Offord) on securing this important debate. We have had a good debate, although fairly brief, and some important issues have been raised.

I formally welcome the Minister. We have had Health Questions and an Opposition day debate on health since he assumed his role, but this is my first opportunity to welcome him. I trust that his time at the Department of Health will be enjoyable and successful.

I am pleased to respond to the debate on behalf of the Opposition. The hon. Member for Hendon is right: the efficiency challenge for the coming years will dominate the debate about healthcare and shape our NHS in England for decades. As Members know—indeed, several referred to it specifically—the Government are committed to seeing £22 billion of efficiency savings in the NHS by 2020 to meet the £30 billion funding challenge. We have not yet heard any details of where the £8 billion in funding will come from; perhaps I can tease some of the detail out of the Minister. I do not wish to prejudge what may or may not be in the Budget, but it would be nice to have some indication, aside from the usual spin about a growing economy, of where he thinks the £8 billion will come from. Setting aside that question, we need to think carefully about how to meet the £22 billion gap that will remain once that £8 billion is found. To achieve savings on that scale would be a huge ask at any time, but when NHS trusts have huge deficits to tackle and providers say they are experiencing the biggest financial pressures they have ever seen, making these efficiencies will be a huge challenge.

It is probably appropriate at this stage for me to place on record my appreciation of and thanks to those who work in our national health service—at every level. It is not always popular to praise managers, but to meet the challenge the NHS will need a great deal of expert management. We therefore need to praise the work of not just the doctors, nurses, clinicians, porters and support staff, but the good managers, because they will face the real challenge of finding these efficiencies.

It is vital, not just for us but for all those who work in the NHS, that the Minister is as open and honest as he can be today about where the efficiencies will come from. One of the few people who has seen the detail of the planned efficiency savings is the former Care Minister, the right hon. Member for North Norfolk (Norman Lamb). Just last week, he said that the £22 billion efficiency savings in the five-year forward view are “virtually impossible” to achieve—words that will not fill people with confidence.

As the Minister knows, the Opposition have pressed the Government on a number of occasions to publish the assumptions underlying the £22 billion figure. I hope he will take that message back to the Secretary of State today, because we need to have a properly informed debate about the NHS’s long-term funding requirements. That is true not just of England, because the proposals will have knock-on consequences for the NHS in all the constituent parts of the United Kingdom, including Scotland and Northern Ireland, which have been represented in the debate.

We need to be honest about the fact that, whatever the scale of the efficiencies that need to be found, there will be no quick fix—a point eloquently made by my hon. Friend the Member for Bristol South (Karin Smyth). However, when budgets are tight, it is right that we debate how money can be better spent to meet the growing cost of delivering world-class healthcare.

With that in mind, let me cover a couple of pertinent areas. The first is procurement. Any doctor will tell us of sales representatives pushing every bit of kit and course of medicine under the sun—that is just the nature of salespeople, and that is what they do. In the NHS, there are around 500,000 product lines for everyday consumables, with cost variances of sometimes more than 35%, which is massive. The Carter review suggested that a catalogue of 6,000 to 9,000 product lines represents best practice. In part, the huge variety of products is a symptom of a more fragmented NHS. These days, we do not have the opportunity to use the NHS’s national purchasing muscle as much as we did, which is a shame and a wasted opportunity. However, having a reduced range of products—perhaps set out in a national catalogue, but definitely coming through the NHS supply chain—would be good for cost-effectiveness. I hope the Minister can take that point on board.

Part of the problem is the army of sales representatives, who are proliferating at all levels of the NHS. Their very existence represents a large dead-weight cost to providers. They can provide a useful service when it comes to selecting the best product for practitioners’ needs, but it is obviously not in their interests to provide products at the lowest practical cost; nor is it in their interests to promote other products or to give practitioners more information about the choices that may be available to them and their patients. It is, to some extent, an imperfect market, with smaller suppliers pushed out from the very beginning. There will always be a need for companies to provide high-end support and advice, but while representatives have a big influence on buying decisions, we must ensure that that influence is at least partly tracked.

Let me talk briefly about the cost of competition. The Minister is new to his post, but he will have paid close attention to the many debates we had on these issues before the election, so he will be aware of the Opposition’s concerns about the competition rules introduced in the Health and Social Care Act 2012. We know that the new competition framework is causing

“significant cost to the system”—

not my words, but those of the former chief executive of the NHS. Last year, we identified at least £100 million that in trusts and clinical commissioning groups alone was being spent on staff and lawyers to analyse tenders and to administer the tendering process. If the Minister is serious about making substantial savings, may I gently advise him that it would be a good start to look at the waste generated by the Act’s competition provisions?

One crucial area to analyse is the poor workflow in hospitals, and specifically the lack of adequate sub-acute services. At the moment, many discharged patients, particularly elderly ones, have nowhere to go. That is attributable mainly to the drastic cuts to adult social care we have seen in recent years. Sadly, I can only anticipate that those pressures will remain, and perhaps become more acute with coming spending reviews. We all know that if patients are not discharged, hospital beds are wasted and hospital workflow is disrupted, which costs the system an absolute fortune. That is to leave aside the fact that hospital is not the best or most appropriate place for such patients to be or for their care to be delivered.

[Karin Smyth]

The consequences of the 2012 Act included fragmentation of responsibility for the flow of patients through the system. Different commissioning organisations now commission primary care to support the patient outside hospital, there is separate provision of community services, and NHS England has an oversight role as well as a role in commissioning specialised services. In Bristol there are two major acute trusts that are largely commissioned by three different clinical commissioning groups, supported by NHS England and involving the Trust Development Authority and Monitor. A large room is needed for people to get around the table at meetings to consider things such as flow, and it is very complicated.

[Andrew Gwynne]

My hon. Friend hits the nail on the head, describing the complexities of the NHS in England. We have talked for several years in the House of Commons about the need for a properly integrated health and social care system. My hon. Friend has set out a prime example of the reason we need that.

I anticipate that the Minister will argue that some of the inefficiencies we have discussed will be addressed through integration. My problem is that many of the competition rules and requirements in the 2012 Act work against such an integrated health and social care system, even though both sides of the House want it. The Government will have to look carefully at the role of some of the rules and regulations they introduced, when local health economies reach the point of developing integrated care models. It is clear that representatives of a hospital trust, local authority adult social care and children’s care services, and the clinical commissioning group cannot sit around a table to plan an integrated health and social care system while many of the requirements placed on the NHS by the 2012 Act continue to apply.

To return to the issue of transfer and delays in hospitals, we all know that the NHS operates something of a just-in-time system. Such systems are used in industry, particularly for international stock control, and they make sure that nothing is wasted. There is little room for slack: if a patient is admitted for longer than necessary because of avoidable shortfalls elsewhere in the system, that can lead to the atrocious scenes that happen when desperately sick and injured people are left lying in corridors. I think that on one occasion, somewhere near the constituency of my hon. Friend the Member for Bristol South, someone was treated in a tent in a hospital car park. We hoped such images had long gone from the NHS.

I want to say politely but firmly to the Minister that the NHS is affected by what goes on in the social care system. Social care cuts are to all intents and purposes NHS cuts. I hope that he will get that message loudly and clearly and that the Prime Minister will stop insisting otherwise. All that demonstrates, as my hon. Friend the Member for Bristol South eloquently stated in her intervention, the need for a properly joined-up service. Labour Front Benchers have argued for that for some time and the previous Government were moving towards it. I am happy to provide guidance to the Minister on what we think should happen to that end, and to provide stern criticism if Ministers do not deliver.

I also want to talk briefly about the cost of agency workers, which the hon. Member for Angus (Mike Weir) touched on. The Health Secretary has belatedly sought to address that issue, but it has been years in the making. Ministers will know that hospitals have consistently cited recruitment difficulties, particularly for qualified nursing and medical staff and in accident and emergency departments. It is welcome that the number of training places has been increased in recent years, but it was a short-sighted mistake to cut the number of those places early in the previous Parliament. That has led in part to the present recruitment issues.

The Minister will know that the rising number of staff suffering from work-related stress has resulted in even more workforce pressures in the NHS. He will also know that the decision to cut nurse training posts has meant that many hospitals must either recruit from overseas or hire expensive agency workers. Health Ministers must make strong representations to Home Office Ministers, because if there was ever a sign of disjointed Government decisions, it was the recent announcement of changes to immigration policy. As we have already discussed, those changes may cause massive problems to some NHS trusts across the United Kingdom that already face challenges and have recruited from overseas.

The savings that the NHS will need to make in coming years are far more difficult than the low-hanging fruit or quick wins that some may think are available. All of us across the parties and across the constituent parts of the United Kingdom need to acknowledge that there will be no quick fixes to the challenge. There should be no mistaking how difficult things have been for many trusts in the past few years. The coming years will be just as difficult for them, if not more so. I hope that the Minister will agree in that context that we need a proper open debate, with all the facts, figures and information before us about where we can make the savings, and how we can ensure that more of the NHS’s funding is spent on what it does best—delivering high-quality patient care across the United Kingdom.

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[The Parliamentary Under-Secretary of State for Health (Ben Gummer)]

It is a pleasure to serve under your chairmanship, Mr Pritchard. It is indeed my first appearance in this role in Westminster Hall and, therefore, under your chairmanship here.

I congratulate my hon. Friend the Member for Hendon (Dr Offord) on securing this important debate. I suspect that, in raising the important matters that he took up in his speech, he did not anticipate the glimpse of the promised land that the debate would give us. I have never sat in a debate on the NHS in this House—I have only been here for five years—when there was such a productive, interesting and bipartisan approach to such an important matter. I hope that it will be a model for things to come.

In seriousness, the differences between us, across the Floor, are far fewer than the things we agree on when we consider the NHS. A new Member, the hon. Member for Bristol South (Karin Smyth), said in her speech that now the election is over we have a fantastic opportunity to forge a greater consensus on the NHS, which will be better for the service and patients, and especially, in the present context, for the people who work in it. They get fed up with the politicisation of the NHS, which has happened since its creation in 1948.

The hon. Lady hit the nail on the head in her excellent speech: efficiency really comes from quality. We begin to get an NHS system that is truly efficient in using the resources that the taxpayer puts at its disposal and the hard work of those who work in it when the first consideration is care quality and safety. If we try to build a system around quality and safety, the efficiencies will flow from that and excessive costs will start to fall out. Part of the problem with trying to find efficiency savings in the NHS—indeed, in any public body or private organisation—is that a purely cost-cutting approach will almost certainly fail, in terms of not only the quality of the product being delivered, but the efficiencies being sought. I very much welcome the hon. Lady’s intervention on that point, because that is where we need to begin.

All of that lies at the heart of Lord Carter’s excellent report. It is an interim report—he will publish his final report, with a great deal more detail, in the autumn—but he has understood that it is the patient who feels the effects of inefficiency first and foremost. Their experience of care is not what it should be, because of how rostering is arranged or medicines are dispensed and administered. He gave specific instances in his interim report—for example, the range of products available for hip replacements—of where choosing one product over another can mean dramatic differences in the occurrence of revisions. As the hon. Member for Strangford (Jim Shannon) said in his speech, cheapest is not always best. Sometimes, a slightly more expensive hip replacement joint can mean a much higher chance that someone does not have to come back for surgery again in a few years’ time. Such decisions about balance lie at the heart of patient care. If we get the balance right, we have a huge prize: better patient care and a more efficient, cost-effective service.

I want to run through the main points of Lord Carter’s report and reflect on them in the terms raised by my hon. Friend the Member for Hendon. The NHS provides a varied picture of efficiency. The service has some of the most efficient hospitals in the world, but also some fantastically inefficient ones. That variation lies at the heart of the problem that we have to square in the next few years, which I will come to shortly when I address the specific points about the £22 billion target. As MPs, we all have anecdotal impressions from speaking to chief executives and managers in the NHS: they have come up with great ideas locally, but one knows immediately that no one is learning from that across the system. That was the case before the 2012 reorganisation, and it was case before all the previous reorganisations; it has been problem in the NHS since its inception.

We must also learn from best practice around the world. There is some fantastic practice around, and not only in France, Spain—specifically Valencia—and Germany; some of the best practice in the world for creating efficient healthcare is in American hospitals. I find it very exciting that there is some fantastic practice coming from Indian hospitals, because it shows how the world is changing. If we can draw in that expertise, we will do better for the NHS. I hope that, at the same time, we will export some of the best practice we have developed here—much of which has come from places not a million miles from the shadow Minister’s constituency—to hospitals and health systems around the world.

The changes in efficiency and productivity gains in the past few years have been considerable. Traditionally, the NHS has lagged behind in productivity improvements, but in the past few years it has overtaken productivity gains in the rest of the economy. Some of that has come from wage restraint, but there has been a genuine improvement in productivity, although it is not as much as we hope, anticipate and need to come over the next five years from system change, rather that just from wage restraint.

Lord Carter’s review covers some of the efficiency savings that can be made, especially in the provider sector. He has identified £5 billion of savings, of which £2 billion can come from improving workflow and workforce costs and £3 billion from static costs related to pharmacies, estates and procurement. As has been mentioned already, he has identified the fact that although there is much dispersed good practice, it is not shared, and there is no common understanding of what a good hospital looks like. On the back of Lord Carter’s principal recommendation, we are going to construct a good hospital. It will be a virtual hospital, so people will not be able to visit it, but they will be able to go to parts of it, because we are going to take the best practice and codify it.

Lord Carter has created a system called the adjusted treatment index, which is a rather dry term for an exciting idea. We will say, “This index is the best that the NHS is doing and we’re going to measure you all against it.” Every chief executive, manager and clinician will be able to see where their particular unit sits against the very best in the country. That will immediately prompt some questions: “Why are we not the best? Why are we a third or half of the way down? What can we do to close the gap?”

The second output from Lord Carter’s report is to provide a suggestion, in base terms, of how the poorest performing hospitals, along with those in the middle and those near the top, can improve and become the best. His final report will give far more detail, but this is of course a living process. We want to create a manual that will help clinicians to constantly improve their performance, measured against the very best—and the very best in the NHS will be measured against the very best in the world, so that our target keeps moving upward.

Lord Carter also identified issues with staffing, agency spend and locums, which formed the meat of the speech by my hon. Friend the Member for Hendon. I will quickly go through what we plan to do. In the long term, it is clear that the expansion of nursing recruitment places will meet our objective to improve staffing ratios and the quality of care in hospitals, but we do have a backlog to fill. I do not want to break the bipartisan consensus, but the fall-off in recruitment places did begin before 2010. It picked up again in 2012-13, partly in response to the recommendations of the Francis report, but we still have some way to go to ensure that we are up to pace.

It has become clear that although there was a need for agency staffing to plug the shortfall, some have been abusing that position. Now that we are getting more and more nurses into the system, it is the right time to bear down on agency costs, which is why the measures outlined by my right hon. Friend the Secretary of State a couple of weeks ago will make such a difference, by giving chief executives the tools to ensure that they are not paying over the odds on agency spend.

[Karin Smyth]

On agency recruitment, does the Minister agree that we should encourage more young people to see the NHS as a good career? Young people such as those in my constituency, Bristol South, do not always get the advantages of university and further and higher education qualifications, and they do not see working for the NHS as a good and positive career. It is still a very good career—well paid and well remunerated by pensions and so on—but it is no one’s job, directly, to sell a career in the NHS in order to bring through the next generation of young people in places such as Bristol South to work in the NHS. That is not a hospital’s direct role. Health Education England is a new organisation and has that responsibility, but, in the spirit of bipartisanship and cross-departmental working, will the Minister take our advice and talk to colleagues in skills and development and support apprenticeships to encourage young people to come through and fill the gap currently filled by agencies?

[Ben Gummer]

I do not want to ruin the hon. Lady’s nascent reputation by agreeing with her again—happily, there are very few Opposition Members present to notice, although that is not an implied criticism—but she is absolutely right. We are lucky that nursing places are quite significantly over-subscribed. The position is popular, but she is absolutely right that we need to not only make far greater use of apprenticeships but widen the skills base in nursing full stop. We are actively working on that in the Department—I have spent much of the day on it, and I am sure there will be more to come.

To help chief executives in this interim period, we have forced all agencies that want to offer their services to ensure that they are doing so through framework contracts, and we are ensuring that there is an hourly cap on the rate that can be charged. We have also taken additional measures on managerial salaries, along with a few other measures, to ensure that managers have the opportunity to be able to manage costs as they wish. We understand, however, that this is the first stage of a much deeper programme of reform that is needed. Lord Carter’s report points in that direction by suggesting that we use our existing workforce far better, so that people are doing the job that they are suited to and qualified for and that their time is not wasted. That is the great win, not only for efficiency and patient care, but for staff enjoyment of their jobs.

The hon. Member for Coventry South (Mr Cunningham) made some helpful interventions about NHS workers’ quality of life. It has been a sad but persistent truth of the NHS for many years—decades, in fact—that staff-reported incidents of harassment and bullying have been higher than the national average and that workforce stress and illness is higher than average. Some of that is to be expected—parts of the NHS are extremely stressful working environments—but we can do much more. Part of that is about ensuring, when people turn up to work, that they are doing the job they wanted to do, with a suitable but not excessive degree of pressure, and that the system is not wasting their time. If we make them happier in their jobs, their patient care will improve and their commitment to the service will be even greater. I am therefore aware of the prize, not just in pounds, shillings and pence, but in an improvement to staff morale and therefore patient care.