Academic Health Science Centres

Lord Willis of Knaresborough Excerpts

Tuesday 2nd July 2019 Grand Committee

[Lord Willis of Knaresborough (LD)]

I, too, thank the noble Lord, Lord Butler, for initiating this debate. Given the number of people who will no doubt speak on behalf of different academic health science centres, the Committee should take it as read that I believe that they are all doing excellent work, because I want to explore one or two other areas.

On the need for a 21st-century research-led healthcare system, there is no political discord whatever—I think that we all agree on that, full stop. When the noble Lord, Lord Patel, managed to get the words “research led” on to the statute book during the passage of the Health and Social Care Act 2012, it was remarkable because it created a journey to which I think we all aspired.

There were some excellent signs. The early establishment of some academic health science centres during the years of the Labour Government was positive. In 2014, it was good to see the re-designation of six of them, five of them being in the “golden triangle” and the other in Manchester. I believed that was exciting but hoped it would pave the way for more. Why is there excellent research only in the south-east rather than elsewhere in the country? So far, that expansion has not transpired. If we simply go ahead and re-designate those already there, what will happen to my area, Yorkshire and the Humber? Are we saying that there are no initiatives worthy of designation in Yorkshire and the Humber or the north-east? Surely not. I hope that the Minister will take that on board.

My first plea in any reaccreditation exercise is to include areas that have a strong track record of collaboration between academia and research. In so doing, please use the opportunity to simplify structures that Peter Drucker once described as,

“the most complex in human history”.

Drucker was interesting, but it cannot be right to have differing governance, finance, clinical and political structures in each of the organisations, most with scant involvement of the people they serve. I have a great deal of time for Drucker but he had not looked at the rest of the health research landscape when he made his comments. As Professor Ovseiko argued in 2014, in a superb article on improving accountability through alignment, unless our model of competing structures for research, education, patient care and funding is radically streamlined we will not realise the huge potential for improved patient care that lies within our grasp.

The current landscape defies logical examination. We now have academic health science networks in every region with a remarkably similar mission to the AHSCs, except that they have a budget. Some have close ties with their AHSC, if it exists—not so in Yorkshire and the Humber—some do not. They should surely be brought together within the AHSN using its organisational structures, which are already there and are being paid for by the taxpayer. What about the collaborations for leadership in applied health research and care—the CLAHRCs—of which I am currently chairman, which are soon to be replaced by another set of organisations, the applied research collaborations, for which I am a prospective chairman? Again, some have close ties with a regional AHSN, some do not. For good measure, how do we ensure that our remarkable research effort actually benefits all our citizens, not simply the regions where the organisations currently are?

Finally, money is essential in this. We have a host of small elements of money. We need this to be properly funded. The whole nation needs to be involved and to take this wonderful opportunity forward.

Nursing and Midwifery (Amendment) Order 2018

Lord Willis of Knaresborough Excerpts

Monday 25th June 2018 Lords Chamber

[Baroness Thornton (Lab)]

I thank the Minister for his excellent explanation of this order, which provides the Nursing and Midwifery Council with the necessary legal powers to regulate the nursing associate profession. On these Benches, we will be supporting the order, and I thank the Nursing and Midwifery Council and the RCN for their excellent briefs.

We are ready to accept that the creation of nursing associates is a welcome addition to building capacity. Some of us who are long in the tooth—there may be one or two in the House today—will remember SRNs and SENs and wonder whether we have gone full circle to move forward. However, I accept that there is some urgency to get this on the statute book because, initially, 2,000 nursing associates were training at 35 Health Education England test sites, with a further 5,000 starts planned for this year. The first nursing associates will qualify to apply for registration with the NMC from January 2019, so I accept the urgency to implement this order.

The Minister says that the nursing associate role is a defined care role to act as a bridge between unregulated healthcare assistants and the registered nursing workforce. Now that that role has been created, we agree with the Royal College of Nursing that,

“there must be absolute clarity that the nursing associate … is not a separate profession, but a new role within the nursing family that works under the delegation of the Registered Nurse”.

It went on to ask for “urgent guidance” to be published on “the precise relationship between” nurse associates and registered nurses,

“in terms of delegation and accountability”.

I hope that the Minister has taken that on board.

It is important to recognise that this new role is not the answer to the huge workforce challenges faced by the NHS and the social care system. Last week when the Government announced their funding proposals for the NHS, and the creation of a 10-year plan, many noble Lords said—we agreed—that it would be meaningless if this does not cover healthcare workers and social care workers together, given their importance in the future of our healthcare and social care system. Given that Health Education England has had its budget slashed, that we have a huge decrease in healthcare workers from the European Union, and the soon-to-be-removed—I hope—ridiculous visa system for non-EU health workers, the fact is that more nurses are leaving the profession than joining it, and there is a demographic challenge in that one in three nurses is due to retire in the next decade. In that context there is a well-founded anxiety that nursing associates could be used as a substitute for registered nurses.

Also in that context, has this new role been thought through, or is it a quick response to nursing shortages, with unfilled nursing posts which, as we know, are at a record high? Linked to that, how do we ensure that this new role does not impact negatively on the social care workforce? The head of Health Education England has highlighted that problem.

The role of a nursing associate was created before this SI was even introduced. Has there been enough time to consider the standards and levels of training for nursing associates to be registered with the NMC? I have to say that I am comforted by two things. One is the comprehensive brief from the NMC which suggests that it is on top of this, and indeed the notes accompanying the amendment order itself. I want to raise two things with the Minister, which are on page 5 of the accompanying notes and concern the cost-benefit impact analysis and the regulation of the nursing associates. Two risks are identified:

“First, there is a financial risk that the agreed initial set up costs escalate beyond those currently agreed with NMC. Second, the unquantified costs mentioned above relating to setting up and/or amending existing nursing associate courses as well as the accreditation of education providers”.


Those risks need to be mitigated before this moves forward in an orderly fashion. Finally, I think that there is provision in the order to take account of European Economic Area nursing associates, but I understand that this is not a uniform description or role that fits the narrative across the board. Will the Minister also comment on that?

[Lord Willis of Knaresborough (LD)]

My Lords, I rise from the second Bench—I am not quite trusted to be on the front yet—

[A noble Lord]

Oh!

[Lord Willis of Knaresborough]

Thank you for your commiseration. I support the Nursing and Midwifery (Amendment) Order 2018. I do so with a very personal endorsement and declare my interest as an honorary fellow of the RCN; as a consultant to HEE and the NMC, with which I have been working on these regulations; and as the author of the Shape of Caring report, which is the origin of the nursing associate proposal. I recognise the work of two people in particular. The noble Baroness, Lady Thornton, kindly and quite rightly mentioned the NMC and the work that Jackie Smith has done to bring this through the process. The NMC was presented with two big issues: the new standards for nurses and those for nursing associates, which it took on at the request of the Government. She has led both those processes admirably. Although she is leaving her post next month, this House, and the profession, owe her a great deal of gratitude for what she has done.

I also want to mention and put on record Samantha Donohue, a registered nurse currently studying for a PhD. Her job has been to deal with all the pilot sites, the 8,000 applicants and the 2,023 colleagues who have started training. This has been a Herculean job; at every stage there has been some objection to overcome. I hope that, when he responds to this debate, the Minister will recognise that at times we have in our midst people who do fantastic jobs and do not require to be told how to do them by people elsewhere: they just get on and do it.

The noble Baroness, Lady Thornton, suggested that this matter has been rushed through. I understand that the regulation has followed the start of the pilots but, as independent chair of the Shape of Caring review, it took me over two years’ work to produce the 34 recommendations that led to this process and the recognition that nursing standards needed to change. Quite often, we look at the healthcare workforce in silos, instead of looking at it as a complete, interdependent ecosystem. There are also silos within silos in every section of the healthcare workforce—medics, consultants, physios, care workers or registered nurses—each of which fights for its space. When I was doing this work, particularly when I visited the United States and looked at the Magnet hospital set-up, I was drawn to the fact that nurses are right at the centre of and pivotal to a 21st-century healthcare system. Unless you put them at the centre, the rest of it will not work as smoothly as it should.

I totally support the move of the workforce to graduate status, but we have not fully realised the potential of a graduate nurse workforce. This role frees the registered nurses for the leadership in care that they have been prevented from doing because they are bogged down—I do not mean that in a disrespectful way—by the host of other tasks they have to do. The idea of being able to lead this care while safely delegating is at the heart of the report’s recommendations. Both Robert Francis, in the Mid Staffs report, and the noble Baroness, Lady Cavendish, who produced the superb report on care workers, recognised that unless those two groups of workers—the noble Baroness, Lady Thornton, mentioned them, too—are properly trained and get a recognition within the training organisation, you cannot safely delegate to people when you cannot rely on their having the skills to carry out those tasks. The nursing associate fills that gap. It liberates the registered nurse and at the same time makes sure that there is safe regulation. The establishment of the nursing associate is not, as the Minister rightly says, a substitute for a registered nurse; nor is it an investment in their long-term career. It is a point of registration—that is all. This is not the time for this debate, but unless we make provision for ongoing professional development of the whole of the nursing and care workforce, we will not get the benefit from either the nursing associate or the new role of the registered nurse.

I shall ask the Minister a number of brief questions. The first is about the apprenticeship route. I support that route, as I think most Members of the House do, and the apprenticeship levy is an obvious route for employers to take when expanding the nursing associate workforce. There will be a temptation, however, which the apprenticeship route encourages, to tailor the experience of individuals to the needs of the organisation, rather than to recognise that huge strands are working through this role which need to be applied elsewhere. We must not fall into the trap of having people who can work in only one organisation. They need to be able to develop skills that are transferable to wherever they are expected to work. Will the Minister therefore confirm that apprenticeships, in common with other routes into nursing, must be NMC-approved programmes and must be delivered by NMC-approved providers? Will he also confirm that the requirement in the pre-regulation apprenticeship standard that programmes are delivered by NMC-approved AEIs that deliver nurse education will continue? Will he also confirm that any change to those processes will be reported to Parliament for debate?

My second question is on overseas applications. How we deal with that will be a real challenge as we move forward past Brexit. Will the Minister confirm that such applicants will not be eligible for the nursing association register unless they have comparable qualifications from a higher education establishment and have passed a competence test set out by the NMC? I hope the House will appreciate that I am trying to guard against a second class of nurses. We want people whose standards are set and we want to maintain them, wherever they come from. That is important.

Thirdly, on Scotland, Wales and Northern Ireland, I was disappointed—like I think many people in the House—that they are not part of this process. The NMC regulates across the United Kingdom, not just in England, and it is a sad state of affairs that we now have this separation between England and the other three countries. If the countries decide to introduce a similar post, will they be able to instruct the NMC separately to regulate it, or can they introduce a post with identical requirements—let us call it a nursing assistant—without regulation? It would be wrong if we found ourselves within the United Kingdom having different regulatory or non-regulatory systems around the same post in different jurisdictions.

There has been much concern about the new nursing associate role being a role in its own right or an adjunct to a registered nurse. The issue is clarified in paragraph 7.20 of the Explanatory Notes, but I think it will remain an issue. Therefore, will the Minister confirm that nursing associates will not simply be the handmaidens of registered nurses? That cannot be the case. This is part of the nursing profession, full stop. It is part of that family, with a distinct role, primarily to underpin the work of the registered nurse but also to carry out functions in its own right wherever needed. A classic example is nursing homes. At the moment, a host of relatively poorly qualified people are working in nursing homes, often under the direction of just one registered nurse. At night, that provision is often only at the end of the phone. We really must not have that. We must simply say that we want people we can rely on, who will have the confidence of patients and their families.

With those comments in mind, I say to the Minister that in 10 years’ time there will be some 70,000 nursing associates registered and working in the system. What a present it is that, on the 70th anniversary of the NHS, we are establishing a new workforce to supplement and support the existing workforce to deliver an even better NHS.

--- Later in debate ---

The same argument applies to apprenticeships. Who is going to pay the fees? Is it the local employing body? If that is the case, there will be a lot of encouragement for local trusts not to have NAs, because they will have to pay for them. Why are the figures related to that?

[Lord Willis of Knaresborough]

Perhaps I might help. Some of the thinking behind the funding model, in particular for apprenticeships, relates to the levy. It will not apply to very small trusts, but most large trusts have a 0.5% employment levy, and to apply that through the apprenticeship route seems very logical. Whether it will work is a different matter, but that is the logic.

[Lord Clark of Windermere]

I am very grateful for that—and I understand that many trusts contribute to the levy. Perhaps the Minister could give us an indication of what the breakdown will be between the conventional course and the apprenticeship course for nurse associates. That would be helpful, because one has to bear in mind that the cost to a registered nurse undergraduate is £9,000 a year. That is what they have to pay—which means that they will pay £27,000 to get their qualification.

We need to continue at a high level. As the Minister said, we have increased the number of nurses in training; I found that very encouraging. He is absolutely correct. But why should somebody who wants to become a registered nurse spend £27,000 over three years when they could do a conventional NA qualification for two years at no cost, then do another year to become a fully qualified registered nurse? It just does not make sense. The Government have to look at the funding of nurse support training as a whole. I hope that they do so.

I felt that it was right and proper to raise these difficulties as they have not been raised elsewhere because, as I said, many of the consultees have other interests in putting forward their points of view.

Long-term Plan for the NHS

Lord Willis of Knaresborough Excerpts

Tuesday 19th June 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord mentions the figure of 4%. I have looked at a number of think tank reports and their assumptions on what is required. They make some very cautious assumptions of the productivity improvements that the NHS is making, based on historical performance. The improvements in productivity over the last five years are very healthy—in fact, in the last year the NHS became more productive at a rate of 1.8%. If you add that to the 3.4%, that gives an increase of more than 5% in terms of bang for your buck. It is incumbent on us during this process not only to put in more money but to make sure that we are driving those productivity gains that we have seen in the last five years. If that then gives a 5% effective increase in funding, that is what we will need to deal with the long-term pressures that the noble Lord has quite rightly highlighted.

On the three questions, there is an explicit commitment to deliver this workforce strategy that the NHS comes up with as part of its plan. On the extra costs of social care, we clearly need a social care settlement that delivers the funding for those rather than their being covered by the NHS. That is what we mean about the commitment not to create extra pressures. As I have said, the funding will come from three sources—whatever the mix, the funding will be there.

[Lord Willis of Knaresborough (LD)]

Will the Minister accept that in terms of productivity, one of the issues that is holding us back in developing things at speed is the overregulation of the whole of the health system? We have two systems regulators and seven professional regulators; we were promised in 2014 that there would be legislation to simplify the regulatory system. Can the noble Lord assure the House that we will have a bonfire of regulations and put the right regulations in place to move this agenda forward?

[Lord O'Shaughnessy]

The noble Lord speaks with great insight and makes a very important point. There is broad agreement on the need to simplify the structure of the health system but there has not to date been broad agreement on how we should do so. We are expecting in the next few months to explore the potential for the kind of streamlining that he is talking about. I hope that that can be done as a collaborative effort and, if it comes to primary legislation, that we can deliver it as a collaborative effort too.

Education (Student Support) (Amendment) (No. 2) Regulations 2018

Lord Willis of Knaresborough Excerpts

Monday 21st May 2018 Lords Chamber

[Lord Puttnam (Lab)]

My Lords, I will probably not be quite as brief as the noble Baroness, Lady Garden, but I support the Motion of my noble friend Lord Hunt. In doing so, I hope to help the Minister with some experiences from the past, which I think are very germane.

My noble friend Lord Hunt and I entered this House on exactly the same day: 5 November 1997. He came as someone with great authority and experience in the National Health Service; I came from a terribly different world, with the specific job of working for the right honourable David Blunkett—now the noble Lord, Lord Blunkett, then the Secretary of State for Education. We had a crisis in teaching and with teachers. I commend to the House the front page of the Times Educational Supplement from 6 April. It states:

“Missing: 47,000 secondary teachers. In a system already struggling to fill the gaps, some are thinking the unthinkable: is it time for teaching without teachers?”


I would add this: is it time for nursing without nurses?

The situation is very serious because any possibility that the Minister and his department have of resolving the problem depends entirely on the pipeline supplied by the teaching profession. That has a time factor attached to it, which is very important. It took the Blair Government—I worked constantly at the department for education—six years to get back to equilibrium after the teaching crisis. We were short of around 47,000 teachers—ironically, almost exactly the same number that we are short of today.

Here is the problem: a demographic bulge will hit us in 2024. At that point, we will be short of something close to 50,000 secondary teachers. It is totally predictable; we can see it coming. It happens to be coming at a time when the number of graduates entering the profession is, necessarily, quite light because of an inverted demographic. I am sure that the noble Lord, Lord Willis of Knaresborough, will understand and attest to the figures I am giving. We had an enormous problem. This Government have an enormous problem, and the less they solve their educational pipeline problem, by ensuring that there are enough teachers in the system, the worse the nursing problem will get.

I commend the past to the Minister. We learned a powerful lesson between 1997 and 2003. Unless the Minister wants to revisit a similar lesson in the National Health Service, he must address this issue now.

[Lord Willis of Knaresborough (LD)]

My Lords, I thank the noble Lord, Lord Puttnam, for reminding us of those days, which were both terrifying—I say that as an ex-educationalist—and exciting. Meeting the challenge, based on an evidence base, enables you to move forward. I declare an interest, having worked for the past few years for Health Education England since its formation as a non-departmental body, following the 2012 Act.

What I find terribly sad about this SI is the lack of evidence behind the move. I do not know, and I suspect very few people in this House know, whether the move to an all-graduate profession—treating nursing graduates the same as teaching graduates or graduates going into law or other professions—should be done on a loan system. There is an argument for that, but in reality, we have absolutely no evidence to demonstrate that it will be effective, particularly at undergraduate level. Like many Members of the House, I look forward to the student funding review, because at least we will get that evidence base, which will be put before both Houses.

I find what I think is behind this deeply disappointing. Your Lordships spent many months debating the Health and Social Care Act 2012. There were a lot of fierce arguments. One of the reasons why the then coalition Government put forward the proposals was to take many of the decisions, particularly about staffing and education, out of the political arena and give them to an NDPB, to allow them to plan ahead. Health Education England was created for that very purpose. This is doing the exact opposite. It is pointless having an organisation which is there to plan a workforce and then taking away the means by which it can generate that workforce, be it at undergraduate or postgraduate level. It saddens me that after some of the excellent things that have been introduced—I declare an interest as having been involved with the nursing associate proposal—the belief is still peddled that this is somehow substitution. It should not be, it is not and it must not be a substitution. The noble Lord, Lord Hunt, is absolutely right to make that point: we do not want to move back to a lower quality simply to produce more people.

Will the Minister give us an idea of the quality, particularly at undergraduate level? I am sure that he will say that while we might not have as many applicants, we still have as many actual posts and that the quality of people applying for those posts is going up. I can find no evidence at all in the HESA survey that that is actually happening. If it is, I will celebrate it, and I am sure the Minister will tell us. The issue I want to raise—it is why I have spoken in this debate—concerns one of the great areas of weakness at the moment, and that is our ability to recruit and retain mental health nurses. This is a massive issue, and not simply for traditional reasons but because the demographics and the epidemiology show that ever more of us who, like your Lordships, have an average age of 70-plus are likely to have a mental health problem as part of their comorbidities as they get older. Few of us can deny that.

I am working at the moment at how we can provide the mental health workforce in 10 or 15 years’ time. I look around at where there is a stream of potential workers who could come in, and frankly it is at postgraduate level, using psychology graduates. I can tell the House that over the last three years, 49,466 psychology graduates have come out of our universities, yet we have a dire shortage of postgraduate mental health nurses. Instead of proposing, as my work does, that we really target these people to try to fill this gap in relatively quick time, this SI is saying that that is no longer possible, that these people with debts already from their university days—their undergraduate days—will now face having to fund work in a specialist area. Will the Government look seriously not just at narrow shortages but at wholesale shortages, which we certainly have in mental health nursing? Can we find a better way of attracting and retaining these people?

I finish with three brief questions. We are going to get, through the NHS and indeed through private sector organisations, 0.5% of their payroll being spent on the apprenticeship levy. I ask the Minister whether trusts and private sector organisations, particularly those in adult social care, will be able to use part of that levy to create in-house bursaries to support the development of staff. As yet we have not talked about the role of other sectors in bringing these people through. Will that be possible?

Secondly, if the Minister says, “Ah, no, BEIS says that you can use this money only if it is for apprenticeships”, are we able to rebadge postgraduate work in nursing, in the different fields, through the levy to provide the bursary—and, of course, fee remission—as a result of that route? There is a big pool of money coming in here, which could be used much more effectively.

Thirdly and finally, I ask the Minister, in trying to solve this conundrum, to make an assurance to this House that it is quality that we want and quality we must give to the people of the UK—particularly the people of England, to which this SI applies—rather than quick fixes in other ways, which I am sure will come down the track if we do not resolve this matter now.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, I congratulate the noble Lord, Lord Hunt, on securing this debate, and express my gratitude to all noble Lords for speaking. I always welcome the high profile that issues relating to NHS staffing receive in this House and I am always pleased to debate our approach with noble Lords, who I know are motivated by a desire to protect and promote our world-class NHS, and bring both wisdom and expertise.

I will start by explaining the overall rationale behind the reforms that the Government are making. The decision to remove bursaries for nursing, midwifery and allied health profession students and to provide them with access to the student loan system was taken by the Department of Health—as was—in the 2015 spending review. One reason for that was that this group of students had access to less money through the NHS bursary system than students in the student loan system. By moving to the loan system, these students now typically receive a 25% increase in the financial resources available to them for living costs during their time at university.

[Lord Willis of Knaresborough]

Before the Minister goes one second further, will he confirm that the bursary money was free money? They did not have to pay that back. Now they have to pay back the whole loan.

[Lord O’Shaughnessy]

If the noble Lord will let me finish, I will get to that point. Like other graduates, student nurses will be required to repay these government-funded loans only once they are in employment and earning. It is important to state that the student loan repayment terms are progressive. From April 2018, individuals will make their contribution to the system only when they are earning more than £25,000. Monthly repayments are linked to income, not to interest rates or the amount borrowed, and the outstanding debt is written off after 30 years.

I am not the Education Minister in this House, although I seem to be covering this topic not only tonight but in other forums, but it is important to underline that the reason this system was introduced into this country by a Labour Government, reaffirmed by a coalition Government and continued by a Conservative Government, is that it means that the best-earning graduates, instead of having their fees entirely paid by taxpayers, including people who have never gone to university, make a contribution to the costs incurred, whereas those who are lower-earning through their lives, including those who will perhaps never earn more than £25,000, will make no contribution. That is a more progressive system of funding than one in which everybody gets it for free, no matter how much money they make in their life.

As I said, these reforms give student nurses access to more financial support, albeit they have to pay that back if they can afford to do so later in life. It also provides a level playing field with other students. But perhaps most importantly of all, these actions released about £1 billion of funding to be reinvested in the NHS front line. As a consequence, Health Education England plans to increase the number of fully funded nurse training places by 25% from September 2018. It is important to stress that Health Education England has made that decision as an independent body to meet the need for more nurses that we all agree is there.

As the noble Lord, Lord Hunt, pointed out, this equates to around 5,000 more places each year—a major and welcome boost to our much-admired nursing workforce. My background is largely in education and I assure the noble Lord, Lord Puttnam, that we understand the urgency of this task and the parallels with education that he mentioned.

NHS: Nurse Retention

Lord Willis of Knaresborough Excerpts

Wednesday 17th January 2018 Lords Chamber

[Lord O’Shaughnessy]

We know that we have a growing ageing population—I do not doubt that. We have been increasing real-terms funding for the NHS, which is going on more staff. Nurse numbers have increased and I should point out that there are more doctors and ambulance staff. There have been about 40,000 more clinical staff in general in the NHS over the past few years and more to come in the future.

[Lord Willis of Knaresborough (LD)]

Does the Minister accept that roughly 10% of our nursing workforce has left the profession this year? Many of them are new recruits or not long into their careers. It takes about £80,000 to train a nurse. Any employer with any sense would want, first, to retain them and, secondly, when they leave, to know why they have left, where they have gone and how to get them back. What are we doing to track people who leave and what are we doing to attract them back?