My Lords, I shall speak on this group of amendments, and I declare my health and higher education interests, as in the register—and, specifically, my honorary fellowship of the Royal College of Speech and Language Therapists. We have had some excellent speeches, and some forensic analysis, of these amendments, which are so important to ensuring that the workforce is at the centre of the reform programme under the Bill. I cannot match those contributions, so I do not intend to.
However, I would still like to support Amendments 172 and 214, in the name of the noble Baroness, Lady Finlay of Llandaff, to which I have added my name. The noble Baroness spoke eloquently to those amendments, recognising, among other things, the crucial role that allied health professionals play in the delivery of healthcare. It is worth emphasising that allied health professionals are the third largest section of the health workforce, supporting people of all ages with a range of diagnostic and therapeutic interventions both within and beyond health and social care settings. Their contribution can often be overlooked in a narrative that frequently focuses only on the role of doctors and nurses—however important those clearly are.
As we have heard, Amendments 172 and 214 are designed to address those issues. I shall comment particularly on the role of the speech and language therapy workforce; I am grateful to the Royal College of Speech and Language Therapists for its briefing on this matter. There are around 19,500 speech and language therapists in the UK, many of whom have a portfolio career and work part-time. It is estimated that about two-thirds spend at least some of their working time in the National Health Service. Those not working in, or employed by, the NHS may work for local authorities, in schools, in the justice sector—in which I have a particular interest—with speech and language therapists becoming a key part of criminal justice liaison and diversion teams, in the third sector and in independent practice.
However, as already noted, these settings are not represented in current workforce planning. This risks not enough speech and language therapists being trained to meet current and future demand. In turn, this risks people of all ages with communication and swallowing needs not being able to access the speech and language therapy they and their families desperately require. Crucially, there is already a significant backlog identified, comprising unmet need and increased demand—that increased demand exacerbated by the pandemic.
From initial discussions with speech and language therapy services, it is estimated that a minimum increase of 15% is required in this skilled workforce, whereas in recent years the profession has grown by only 1.7% net per year. Amendment 172 would mean that the duty to report by the Secretary of State would include the whole health and care workforce, not only those directly employed by the NHS in England, and Amendment 214 would ensure that workforce planning takes into account the experience and expertise of the whole social care workforce by establishing a workforce board in every ICB area.
I add my support for Amendments 172 and 214, speaking as a vice-chair of the All-Party Parliamentary Group on Speech and Language Difficulties and a patron of the British Stammering Association. These amendments, which again have the support of the Royal College of Speech and Language Therapists, would do much to safeguard the position of that now rare commodity— speech and language therapists. As has been said by both noble Lords who tabled the amendment, they do not all work in the NHS.
The view of the Department of Health and Social Care is that speech and language therapists should be added to the shortage occupation list, because the profession is facing a range of pressures, including increasing demand in mental health in particular. The NHS long-term plan identified speech and language therapy as a profession in short supply. The need for those therapists must be taken account of in workforce planning.
Similarly, Amendment 214 provides an incentive to ensure that there are enough speech and language therapists to meet current and future demand, which is just not the case at present. I remind noble Lords that meeting communication needs, as well as ensuring the ability to swallow safely—both at risk from a wide range of conditions—are an essential component of well-being, and often safety itself. I hope that the Government will look favourably on these amendments.
My Lords, most of what needs to be said about this group of amendments, which I support, has been said, and said brilliantly well—it has been a wonderful debate. However, I would like to make one more key point. I chair University College London Hospitals Foundation NHS Trust and Whittington Health NHS Trust. In the last two years, during Covid, much of my time has been spent not in your Lordships’ House but walking around both of those institutions, saying thank you and listening to my exhausted staff.
One of the key reasons for putting the issue of reporting to Parliament on workforce planning into the Bill is that our staff—not just their organisations but the individuals themselves—want it to be there. They know what the issues are; they live with the shortages and they know that it has not been thought through. My noble friend Lord Stevens made that very clear: it has not been thought through. If they are not taking early retirement, as some are, they are living with the consequences. We could and should do so much better for them, and for the long term—and our staff know that. For their sake, if for no other, we must put this on the face of the Bill.
My Lords, this has been an extremely rich and vital debate on crucial amendments, albeit conducted in two parts. I will briefly offer the Green group’s support for all of these amendments. I aim not to repeat anything that has been said but to offer some uniquely Green perspectives on this set of amendments.
I will take them in two groups, starting with Amendments 170 and 173 in the names of the noble Baronesses, Lady Cumberlege and Lady Merron. These are particularly important because they very clearly and explicitly lay out the responsibility of the Secretary of State. When I tabled some amendments last week on the Secretary of State’s duty to provide, they met with something of a frosty reception in some quarters—but it is clear from all sides of your Lordships’ House that it has to be the responsibility of the Secretary of State to ensure that there is a plan for the workforce. I stress that that is coming from all sides of your Lordships’ House.
It is worth referring to the King’s Fund briefing, which I do not think anyone has mentioned yet. I will quote one sentence:
“The measures in the Bill to address chronic staff shortages remain weak.”
That is what a respected outside observer says. Your Lordships’ House is seeking to plug that gap. The noble Lord, Lord Lea, suggested that this was all terribly difficult, and that is undoubtedly true, but a lot of people have been thinking about this for a very long time. I was at a briefing for the Royal College of Physicians before the pandemic, in person, with no masks in sight. It was more than two years ago and they were talking about the need for workforce planning, saying, “We know how this should be”. Indeed, on the Royal College of Physicians’ website, more than four score organisations are listed as backing these amendments for workforce planning. So the support is very much there.
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I come now to a second group of amendments—Amendments 86 and 214—which look at local responsibilities. I want to make the point that in many cases the needs are local, and that if you train up local people who are already embedded in the community, they are very likely to stay in the community. That is why it is crucial that we have local plans and training pathways, so that a care worker who might want to take those care skills and then become a nurse and maybe a doctor over a lifetime of learning and education can bring all those different skills together, stay in one community and bring all those skills to that community.
I think it was in an earlier debate that the noble Baroness, Lady Brinton, referred to the problem of the shortage of dentists. We have just had the Great British Oral Health Report, and one stat from that which really struck me was that 22% of people in the north-west have not been able to register for a routine dental appointment. This is just the kind of supply problem we are seeing all the time. In the Morecambe Bay area, there are only 49 dentists for 100,000 people, which is obviously grossly inadequate.
I will make one final point, which picks up points made in particular by the noble Lord, Lord Kakkar, and the noble Baroness, Lady Whitaker, about the global aspect of this. There was a recent report from the International Centre on Nurse Migration, working with the International Council of Nurses, which stated that there is now a global shortfall of almost 6 million nurses. On top of that, it is estimated that 13 million more nurses will be needed over the next decade. Currently, the whole workforce is 28 million. This picks up a point that the noble Lord, Lord Patel, raised about pay erosion for all medical professionals, but it is particularly evident with nurses. The noble Lord, Lord Lea, again said that it was difficult to plan. We have to acknowledge that any medical professional in the UK can potentially take those skills and find a ready place to use them all around the globe. We know that many British doctors have gone to Canada, Australia and all around the world—and nurses the same.
We are a wealthy country. Traditionally, we have imported these skills, all too often from places that have a gross shortage—even far greater shortages than we have. We have to stop doing that. We have to train significantly more people than we need, because quite a number of them will, for whatever personal reasons, decide to go elsewhere, even if we are providing them with the best possible working environment we can. So we have to train vastly more people. That is our global responsibility.
My Lords, I start by acknowledging—as I am sure we all do in your Lordships’ House—the value, commitment and contribution of the workforce who are the backbone of our health and social care services. We owe them our gratitude. The noble Baroness, Lady Finlay, and my noble friends Lady Whitaker and Lord Bradley are all absolutely right to acknowledge the breadth and depth of the workforce: that it is a team, and that each part of that team is absolutely connected with the other.
I very much agree with the noble Lord, Lord Kakkar, who said that this debate is absolutely central to all that we are here to discuss and to all that patients need from our health and social care services. I am extremely grateful to noble Lords who have tabled and supported amendments and spoken in this debate. All of them have made a compelling case for a workforce plan that will, if these amendments are taken on board by the Minister, feature a laser-like focus on valuing the entire staff team, along with providing planning, financial resources, responsibility, reviewing and reporting—all essential features of any effective strategy. This begs the question: if we see these pillars in a strategy in every other part of our economy and of the way that our whole society functions, why can we not have this for the NHS and social care?
I am glad to have tabled an amendment that calls for a duty on the Secretary of State to ensure that there are safe staffing levels—this was very clearly emphasised by the noble Baroness, Lady Walmsley, in her opening to this debate. This is extremely important because it places a duty where it ought to be and allows examination and transparency.
Of course, we all know that the situation we are discussing today is not new: the noble Lord, Lord Stevens, spoke to your Lordships’ House about a litany of unfulfilled promises and missed opportunities in workforce planning. The noble Baroness, Lady Harding, spoke of her efforts to resolve this and explained the need, which we see in these amendments, to introduce improvements to the Bill to resolve the matter of workforce supply against the demand that is there. All of that requires a lead-in time, and it has to be underpinned by the requisite funds—there is no shortcut to this. In England, we now have a whole website that is full of guidance, and NHS boards are required to take this into account, and yet there is no national workforce plan or credible plan for funding. Until there is, the ICBs will not be able to plan either. The noble Lord, Lord Warner, rightly pointed out that this is not an either/or situation: we need a national workforce plan, and it has to have the funds to deliver it.
Well, this has been another fascinating debate, and I welcome the contributions from all noble Lords speaking from many years of experience, including former chief executives of the National Health Service and former Health Ministers, medical experts and practitioners. I am grateful to the many noble Lords who have laid amendments in this group; there clearly is a strength of feeling, not only in this Chamber but in the other place. To cut a long story short, this will clearly require more discussion.
However, I am duty bound to give the Government’s perspective on this. We have committed to publishing a plan for elective recovery and to introduce further reforms to improve recruitment and support our social care workforce, as set out in the White Paper, People at the Heart of Care: Adult Social Care Reform. I take the point of the noble Lord, Lord Stevens, that he is aware of many expectations that have passed, and I hope that this time we surprise him. We are also developing a comprehensive national plan for supporting and enabling integration between health, social care and other services that support people’s health and well-being.
The monthly workforce statistics for October 2021 show there are record numbers of staff working in the NHS, with over 1.2 million full-time equivalent staff, which is about 1.3 million in headcount. But I am also aware of the point of noble Lord, Lord Warner, that it should not just be about the number of people working—it is about much more than numbers and quantity; it is about quality and opportunities. We are also committed to delivering 50,000 more nurses and putting the NHS on a trajectory towards a sustainable long-term future. We want to meet our manifesto commitment to improve retention in nursing and support return to practice, and to invest in and diversify our training pipeline, but also, as many Lords have said, to ethically recruit internationally.
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On Amendments 170, 171 and 173, the department has commissioned HEE to work with partners to develop a robust long-term strategic framework for the health and social care workforce for the next 15 years, which for the first time includes regulated professionals working in adult social care such as nurses and occupational therapists. The report provided for in Clause 35 will also increase the transparency and accountability of the workforce planning process. However, this amendment would require an independently verified report to be published every two years with the assistance of HEE and NHS England. Given what we have heard tonight about some of the long lead times for training of health professionals, there is a concern that publication in a two-year cycle could be seen as too rapid given the long lead times for many health professionals.
However, one of the things to be welcomed is the different pathways into nursing. There are nursing apprenticeships, and there are also different pathways into becoming a doctor. If you have been a nurse and you have worked a certain number of hours, you can train to become a doctor. That shows that we are being innovative with regard to the different pathways into different jobs in the health and care sector.
Last year, we announced our intention to formally merge NHS England with HEE. The transfer of HEE’s functions to NHS England is subject to parliamentary approval. If approved, this will help ensure that service, workforce and finance planning are integrated in one place at a national and local level.
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For speech and language therapists, establishing an advisory workforce mechanism would help to address current weaknesses of workforce planning in the country. In turn, this would support better service planning and delivery, ensuring that there are sufficient speech and language therapists to meet current and future patient need. I strongly support these amendments, which recognise the value of allied health professionals across many services, who will play a crucial role in the integration of care, which is the purpose of this Bill.
Since the debate has picked up Amendment 285 on the proposal to establish an office of health and care sustainability, I add my voice in support. I was a member of the ad hoc Select Committee on the Long-term Sustainability of the NHS, so ably chaired by the noble Lord, Lord Patel. It was one of that report’s recommendations, and our key recommendation, and we will pick up that debate on another group. In the light of the comments already made on that issue, I recommend our recommendation to this Committee as we develop our thoughts on this Bill.
I hope that the Minister will give a very positive response to ensuring that the role of our allied health professionals is embedded in the plans that will come forward, crucially, on the workforce in our health and care system.
That focuses particularly on the medical side of things, but I will refer also to the Age UK briefing. We have had some very valuable contributions about care workers from the noble Baronesses, Lady Verma and Lady Hollins, but Age UK considers that we need to look at this much more broadly. It is calling for a robust accreditation scheme for care workers working in CQC-accredited facilities. We need a different system.
I think it was the noble Baroness, Lady Hollins, who talked about how this is a low-pay sector, but we also need to talk about this differently and recognise that it is also a high-skill sector. I think of some of the care workers whom I have met: care workers who cared for doubly incontinent, aggressive, advanced Alzheimer’s patients, and who had done so for decades. Anyone who claims that these are not people with amazing levels of skill really is denying an obvious fact. We need to acknowledge the skills of care workers and to make sure that they are appropriately remunerated.
I want to pick up another, perhaps specifically Green Party, point that no one else has picked up on. I noted that the chief executive of NHS England was recently forced into a new deal with private hospitals, which she said did not provide good value for money. The deal provides more care in private hospitals to help recovery from the Covid pandemic; it sees the Government going against NHS England and deliberately pushing up the role of the market in healthcare. For those who deny that this is happening, I am afraid this is very clear evidence of it.
I turn to a report of the Centre for Health and the Public Interest, which notes that the great majority of private hospitals rely entirely on NHS staff contributing outside their NHS hours on a self-employed basis. We are talking here about doctors and associated health professionals such as anaesthetists and other clinicians. The NHS paid for their training, pays for their pensions and covers their insurance, yet we talk about private hospitals “helping the NHS”. Listening to this debate, I think that perhaps as part of the amendments on Report, we need to think in the context of workforce planning about the financial contribution to be made by the private sector to the cost of training to adequately recompense the NHS for what the private sector gets out of it to make profits.
I will draw the Minister’s attention to particular aspects of the amendments: explicit recognition of the need to consult with the workforce through trade unions; that planning must cover health and social care; that timescales for reporting should be testing but not too onerous; and that the financial projections in any workforce plan should be subjected to some level of independent expert verification, through the Office for Budget Responsibility, for example.
Behind all of these discussions, we started in a place highlighted by the noble Baronesses, Lady Masham, Lady Walmsley, Lady Watkins and Lady Bennett, and other noble Lords, who spoke of the crisis of the levels of vacancies that we now see and the impossibility of dealing with this without preparation and resource. Any national plan for the workforce needs to be built from the bottom up and not imposed from the top. I hope that the Minister will consider this when he looks at ways to improve the Bill.
I will raise a couple of related points. The scale of the workforce challenge is well established, but it goes far deeper than just numbers and structures. It goes to issues around workforce terms and conditions and career development, particularly in social care, which the noble Baroness, Lady Hollins, brought our attention to. It also has to deal with cultural issues; there is a clear indication that all is not entirely well in the NHS when it comes to diversity, whistleblowing and aspects of how staff are or are not nurtured and supported.
I have one final specific issue to raise, which we have heard about in the debate today and that I would like to extend: international recruitment. I ask that the Government do more to prevent international recruitment, particularly of nurses and midwives, from countries where it is unethical to recruit, and that this be a part of any future strategy. The existing code of practice on international recruitment is not legally enforceable, so when Unison or others report breaches of the code by recruitment agencies, there is no provision for sanctions to be brought against rogue operators. I ask the Minister to confirm that the code of conduct will be promoted and will be enforced.
The situation in which we find ourselves is fixable. I hope the Minister, in his response tonight, will show your Lordships’ House that he understands the situation, that he understands what needs to be done and that he will do it.
On that, I want to make two points. The first is this. When I had a similar conversation with the Kenyan Health Minister and expressed the concern we had about taking nurses who could work in that country, the Minister was quite clear that they actually train more nurses than they have capacity for in their country—they see this as a way to earn revenue. There have been many studies on how remittances are a much more powerful way of helping countries, rather than government-to-government aid. With that in mind, we recruit ethically, and we have conversations.
The second point is also from my own experience. I was on a delegation to Uganda a few years ago and I remember speaking to a local about the issue of the brain drain and our concerns. We were talking about immigration, and he said, “You do realise, though, it is all very well for you to patronise me and say that I should stay in this country, but sometimes the opportunities are not here for me in this country. You talk about a brain drain; I see my brain in a drain”. Sometimes we have to look at the issues of individuals who are concerned that they do not have opportunities in their countries, even if the numbers dictate otherwise. Having said all that, we are committed to the WHO ethical guidelines, but I also think that we should be aware. Look at the way that, post war, the people of the Commonwealth came and helped to save our public services. I hope we are not going to use this as an excuse to keep people out, though I understand the concern that we have to make sure that we recruit ethically internationally.