Health and Care Bill

Lord McNicol of West Kilbride Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 24th January 2022 Lords Chamber

Amendments 79 to 82 not moved.

[The Deputy Chairman of Committees (Lord McNicol of West Kilbride) (Lab)]

We now come to the group beginning with Amendment 83. The noble Baronesses, Lady Brinton and Lady Masham of Ilton, will be taking part remotely.

Amendment 83

Moved by

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[Baroness Walmsley (LD)]

My Lords, in moving Amendment 83 in my name, I want to speak to Amendment 86, also in my name, and to support Amendments 146, 170 and 171.

Everybody taking part in these debates, including the Ministers, would acknowledge the central importance of the staff of the NHS and social care, at every level, and their training, well-being and retention. However, it was clear from the evidence on the workforce to the committee and in debates in the House in another place that there is broad concern that planning for the provision of sufficient of the right staff in all areas has not been good enough. Given how long it takes to train a doctor, an allied health professional or a nurse, excellent forward planning is essential. Proposals were made in another place to improve that in the future but, unfortunately, the Government would accept only a mandated review every five years. This group of amendments is this House’s opportunity to try again, and I hope the Minister will be able to help us.

These amendments show that, in the opinion of noble Lords, the planning of health, public health and care staff must be based on an accurate, independently verified understanding of both the current situation and, as well as can be predicted, future need. Because the political responsibility lies with the Secretary of State, this information collection and planning must exist at the very top, as well as at NHS England and the ICS commissioning level. Clause 35 refers only to the workforce needs of health services, but Amendment 170 lays down detail on what the Secretary of State must do to fulfil this responsibility, not just for health but for public health and social care, since they are so interlinked. We look forward to the White Paper and legislation on social care and hope that workforce issues will be well covered in them, but we need to address it now, in this Bill, even though it would have been better to hear the Government’s proposals on social care first. Amendment 146 says what must be done at ICS level. Crucially, both amendments require appropriate consultation. But there is something I would like to add, and that is where my Amendments 83 and 86 come in.

Every hospital trust and primary care setting has done the work to identify and agree the safe staffing levels of each type and seniority of staff in each setting. This is based on an understanding of the local context and of the knowledge and skills needed for patient safety to deliver each treatment, and an assessment of how many patients can safely be looked after by each member of staff. This varies enormously from setting to setting—from a whole team of staff to each patient in operating theatres, to one-to-one in ICUs and premature baby units, and to several patients to one member of staff in less acute areas.

During the pandemic, we have seen these levels necessarily abandoned, with, for example, one ICU nurse being asked to care for two or even three patients at the peak. This has been an unusual crisis situation and services have had to be flexible, moving staff from one department to another, always, I hope, under the supervision of a staff member with the correct speciality. Hospitals have helped each other and ambulances have been diverted when no bed could be found for patients coming into A&E. That has been the advantage of having a National Health Service.

It has been very difficult for staff, and many have quit their jobs. We started the pandemic with tens of thousands of doctor and nurse vacancies, and the BMA has calculated that we currently have a shortfall of 50,000 full-time equivalent doctors—more than the number of unfilled posts. Our doctor-patient ratio is 25 years behind that of similar OECD countries. In the UK, before the pandemic, there was already a shortage of around 50,000 nurses, and still the healthcare system is nowhere near bridging that gap. In December 2020, a report by the Health Foundation, Building the NHS Nursing Workforce in England, said that the Government will need to exceed their target of 50,000 new nurses in England by 2024-25 if they want the NHS to fully recover from the coronavirus pandemic.

In January 2021, a survey by Nursing Times indicated that 80% of nurses feel that patient safety is being compromised due to this severe staff shortage, which is why my amendments focus on safe staffing levels. While there has been a good increase in the number of nursing students starting courses during 2020, this will not alleviate the issue of a lack of qualified nurses now or in the medium term. There are particular shortages among mental health and cancer support nurses. Cancer Research has also told us that one in 10 cancer diagnostic posts in England is vacant, which threatens the Government’s cancer target. There are also considerable shortages in other allied professions.

We have also seen a reduction in the number of in-patient beds in the last 10 years and bed occupancy rates well in excess of the recommended percentage. Even before the pandemic, some hospitals had no available beds at all during the winter period, leading to nearly every winter period being labelled a crisis. All this is because of the perennial failure to train enough staff.

Despite the increased use of technology, health and care continue to be people businesses, but there has not been enough effective planning to provide the workforce needed, not just for normal services but to provide the resilience needed for the winter and for future pandemics. This has partly been due to “leaky bucket” syndrome—the failure to retain staff because of the pressure and, in some cases, pay or pension issues. That must change. Health Education England is now to be incorporated into NHS England, and the Bill and the forthcoming social care legislation are opportunities to start again. We have one and a half million care workers, with high turnover. In order to improve retention, good training and a career path are needed.

I turn, however, to the detail of my amendments. Included in the duties of the new ICBs is, as set out in Clause 20, in new Section 14Z41, a duty to promote education and training. My Amendment 83 adds to that duty that it should train enough of the right staff to reach safe staffing levels in all areas. My Amendment 86 adds to new Section 14Z42, which covers the duty to promote integration, a duty to improve the ability of NHS and care staff to carry out their duties within safe staffing levels.

The latter amendment recognises the risk to staff themselves as well as patients when they are forced to work with fewer than the prescribed safe number of colleagues, or to extend their shift by many hours because there is nobody to take over. It is a risk to their physical and mental health and it certainly does not help the ability of student nurses and doctors to learn from their senior colleagues when they do not have enough time to breathe. It also causes burnout, leading to significant numbers of doctors and nurses considering leaving the profession or reducing their hours. Some 32% of respondents to the BMA’s April 2021 Covid-19 tracker survey said that they were now more likely to take early retirement, while half reported being more likely to reduce their hours.

I believe that safe staffing levels are part of the duty of care that employers owe to their employees in the health service. However, the Nuffield Trust, Health Foundation and King’s Fund have estimated that, by 2030, the gap between supply of and demand for staff employed by NHS providers in England could reach almost 350,000 full-time equivalent posts if nothing is done. Worryingly, that was based on pre-pandemic calculations. Overcoming unsafe staffing levels is an essential measure to ensure patient safety and to boost the well-being, morale and productivity of staff and, therefore, their retention. The Bill is an opportunity for the Government to take sustainable action to alleviate issues relating to workforce supply and demand in England.

The duties proposed in Amendments 146, 170 and 171 would be welcome, and I support them, but they are not enough. I think that safe staffing should be specifically mentioned among the duties of the ICB, and that is where my amendments would put it. I beg to move.

[The Deputy Chairman of Committees (Lord McNicol of West Kilbride) (Lab)]

My Lords, we have two noble Baronesses taking part remotely. I first call the noble Baroness, Lady Brinton.

[Baroness Brinton (LD) [V]]

My Lords, the present Health Minister and his predecessors for a number of years—far too many years, frankly—should not be surprised by these amendments, all of which cover the issue of workforce planning. Often, Ministers’ words and aspirations have been supportive but the reality is that, without proper long-term workforce planning, the NHS and our social care sectors will struggle to be able to plan for the medium term, let alone the short term.

My noble friend Lady Walmsley introduced this group by saying what is needed in workforce planning and why, and I support her brief but critical amendment to ensure patient safety. The other amendments in this group set out the how: whether the workforce planning reports or clinical and healthcare training needs in Amendment 171, the duty on the Secretary of State in Amendment 173, the report on parity of pay in Amendment 174 or the important Amendment 214 from the noble Baroness, Lady Finlay, on workforce boards. I am looking forward to hearing the expert contributions to follow on them from the noble Lord, Lord Stevens, and many other noble Lords, and I hope that the Minister will take note of how the lack of effective workforce planning is hobbling the provision of health and care services in England.

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We have to have clear career pathways linked to workforce planning, not just in the NHS but in social care. We cannot have the position we have at the moment, where social care is being denuded of nurses because they are all going to the NHS, which can offer them more pay. Above all, we need a key tool for the design, funding and delivery of health and care services in England in future. These amendments, especially Amendment 170, set out how we can do that. I look forward to the Minister’s response.

[The Deputy Chairman of Committees (Lord McNicol of West Kilbride) (Lab)]

My Lords, we have one more noble Baroness taking part remotely. I invite the noble Baroness, Lady Masham of Ilton, to make her comments.

[Baroness Masham of Ilton (CB) [V]]

My Lords, I am very supportive of this group of amendments. There cannot be a safe, effective National Health Service without an adequate, well-trained workforce in hospitals, in care homes and for people who need care in their own homes, as well as adequate GPs and community staff.

At this time, it is more difficult than ever to recruit, as so many nurses and carers left to go back to Europe and the world has been struck by the coronavirus. Many people are off sick with the virus or isolating, and some are tired with stress and overwork. It is not helped when the relations and partners of patients have not been allowed in to help disabled and elderly patients in hospitals. They can help with feeding and giving patients extra help and support, which staff do not have the time to do.

The Royal College of Nursing says that the Bill gives

“no assurance that the system is recruiting and training enough staff to sustainably deliver health and care services.”

As has been said, there should be forward planning for the workforce. For example, the biggest barrier to improving early diagnosis of bowel cancer is long-standing staff shortages in endoscopy, pathology services and gastroenterology, with 43% of advertised posts not being filled. This is really serious. With so many posts across the country not being filled, a variety of specialties are so badly needed. There must be more training opportunities. Without adequate training, there will be no hope of filling the unfilled posts.

It would be very welcome if the Government brought some amendments on Report to help make the recruitment of staff, who are so desperately needed, more successful. Without enough staff, all the important things your Lordships have been discussing today, such as innovation and research, will be unachievable. A thriving workforce is absolutely essential.