NHS Workforce: England

[Mrs Madeleine Moon in the Chair]

I beg to move,

That this House has considered the legal duties of the Secretary of State for Health and Social Care for NHS workforce planning and supply.

I am a nurse. My daughter is a nurse. Nursing is in my family and fundamentally informs who I am and what I do. Last November, I triggered a debate about investing in nursing higher education. I am here today to again carry the burning flag for the nursing profession, the wider health and care workforce, and society.

I will start by directly addressing the notion that we should not seek to further clarify the Secretary of State’s legal duties and powers. I have heard that the latest legislation sought to remove political interference in our health system. I have heard people say, “Don’t make health a political football.” Lastly, I have heard that changing the legislation to give the Secretary of State accountability for the workforce would put health and care back under political control—as if our ability to access health and care was ever out of political control.

I am sorry, but those are laughable positions. Which- ever side of the fence we sit on, it is a serious point that health is fundamentally political. It can never not be political, in terms of what we can access and what happens to people. Our great health service was created within a political agenda, and creating it was a fundamentally political act. Supporting our health and care service to thrive will never not be a political decision. Let us be proud of our history, recognise that health is political, and find a solution to the problems we face.

Now that I have addressed those weak positions, let me state that I, and many others across the political spectrum, take no issue with the idea that there should be explicit clarity in the law about the Secretary of State’s responsibilities. I am not alone in my gratitude for all that our health and care staff do. They work constantly to provide quality care by putting patients at the heart of what they do. In the NHS and the independent sector, nursing accounts for one in 10 of the labour market of the whole of England. We are, and ought to be, a fundamental force to be reckoned with.

Thanks to the scale and urgency of the workforce crisis, many people have been looking into these issues—some of us would say for far too long, and to poor result. We have a long-term plan for the NHS and an interim NHS people plan, so we have seen some movement in the way that agencies work together. However, we have no understanding of what the social care sector needs, and no assurance of workforce funding, which is entirely dependent on the forthcoming spending review and subject to the whim of a new Prime Minister. We do not have a workforce strategy that meets health and care service requirements, or that projects the future needs of the people who live in this country.

The vacancy rate has reached alarming levels, with almost 40,000 nursing vacancies in the NHS in England alone. That is not the full picture. The extent of the vacancies within social care and public health is unclear because it is not mandatory to collect workforce data. It is not possible for services designed with staffing built into their planning to run safely and effectively with so many missing staff.

Fewer people are joining the nursing profession and more are leaving. Since the referendum on the UK’s membership of the EU, more than 10,000 EU nurses and midwives have left the UK workforce. I will not be drawn on Brexit in this debate. However, while we are trying to find our way through the referendum result, frontline staff are propping up the health and care system with no credible assurances that the situation will be resolved. Our professionals are holding on as best they can, but we need to be realistic about what we can reasonably ask of them. They are starting to vote with their feet, and there is not yet the accountability to help us navigate the future that is to come.

This crisis has come about because there is no clarity in the existing legal powers and duties that would ensure that enough staff with the right skills are in the right place at the right time to provide safe and effective care. That is true not just of nursing but of every profession working within our commissioned, taxpayer-funded services, including nurses, medics, psychiatrists, physiotherapists, psychologists, paramedics, pharmacists, social workers, support workers, occupational therapists and dietitians. Literally no one—no one person—is accountable for growing and developing our health and care workforce to meet patients’ needs, now and in future.

The Secretary of State’s current legal duty is to provide a comprehensive service. The Government may say that the Secretary of State has oversight of the workforce through those general duties and powers. With all due respect, the Secretary of State’s responsibilities are too broad to understand what aspects of workforce provision they include. There are also no particular workforce duties within the range of national organisations responsible for service design and delivery. In a health and care system as complex as ours, it is easy for everyone to lose sight of ensuring that we have enough people. Clearly, that is exactly what has happened.

Surely two reasons for the number of vacancies are low pay in the public sector generally and the lack of bursary provision to recruit new nurses. Does my hon. Friend agree that there is a golden opportunity for many mature women, whose children have grown up, to enter that profession? Recently, even ambulance drivers had to pay extra for their certification—I had a debate on that a couple of months ago.

My hon. Friend is right, and I will touch on the removal of bursaries later.

A huge amount of effort has been required to try to fix this mess. There has been progress in the NHS, but it is too little and too slow. It does not include social care and deals only with the immediate context. Many of us in this House are here to challenge the position that the existing so-called responsibilities are clear and robust enough for use by the Government and the health and care system, and for the public to have confidence that the Government can be held to account—now and in future, since the pressures on the system will continue to grow and change.

Yesterday, many of us met nursing staff, having been brought together by members of the Royal College of Nursing, who are all passionate about patient care and public safety. I am moved by their advocacy for the profession, patients and society. I also feel their desperation in the situation they face, trying to keep people safe in challenging environments. Given that professionals have been raising the alarm for decades, hopefully our demands for an end to the boom-and-bust cycle in the workforce will be met.

Even the High Court recognises how vague the current powers and duties are. The legal dispute between the Secretary of State and junior doctors over their contract resulted in a judicial review in 2016. The Court judgment said that, as stated in the National Health Service Act 2006, the objective of “protecting the public”, with a duty on the Secretary of State to take appropriate steps, leaves

“considerable leeway to the Minister as to ways and means”

of running the service.

Anyone who looks at the content of the law can see clear holes and gaps. In addition to the Secretary of State having no explicit responsibility, we have other problems with the duties and power of the national guidance. For example, Health Education England is the organisation responsible for developing our workforce, but its hands are tied because it does not have sufficient legal powers or funding to invest properly in the educational provision needed to grow our workforce. HEE can do planning but not supply, which ought to be the responsibility of the Government. The current legal framework is simply not fit for purpose.

I congratulate the hon. Member for Wolverhampton South West (Eleanor Smith) on securing this debate on an issue that she and I have discussed—her office is near mine in Norman Shaw North—and both care deeply about.

I am glad to see the Minister in his place. He knows my constituency well and understands the challenge of getting to it. In fact, he was the first MP ever to visit me in the heady days before 2010, when I stood as a parliamentary candidate because I thought that coming to Parliament would be a great way of changing the world. I have since learned that that is probably not the case.

The credit should really sit with the people who work in the NHS. In particular, I pay tribute and send my thanks to those who work in West Cornwall Hospital in Penzance, Helston Community Hospital—or cottage hospital, for those of us who grew up there—and other places where NHS staff and others do a fantastic job in really difficult situations, as we have heard. They make sure that people who arrive for whatever reason get the best possible care.

I was keen to take part in the debate because I recognise that things need to be done. We must take responsibility for the way things are at the moment, and although I understand what the legal responsibility is and the reason for the debate, I want to understand a bit more about the solutions, too. I have never thought that all the solutions can be created, thought up or delivered here in Westminster or in any Government Department. Although real progress in integration and improving services on the ground needs to be enabled through legislation, support and encouragement, people in health and social care in Cornwall have got together and worked extremely hard for many years to deliver a system in which pathways and integration are much better than when I welcomed the Minister off the train.

One problem of many is the workforce, which is undoubtedly a challenge. There is also no doubt that the NHS 10-year plan is a fantastic document, but it depends heavily on workforce. I know that the Minister will agree and will want to ensure that we have people in place. We may not participate in this Chamber, but across Parliament, the bunfight, debate and arguments about the NHS go on, and have been taken up by people in local campaigns and the media. That has created an environment in which people choose not to nurse or do anything else in the NHS because they are misinformed. I know of lots of people who would have gone into or considered going into nursing or social care, but will not do so because the NHS is a political hot potato.

On the hon. Gentleman’s point about people not joining the NHS to nurse, the lack of bursary is a significant issue. If someone wants to train, the bursary is really important.

I am addressing the point the hon. Member for Wolverhampton South West made about the importance of working cross-party, as we will in this Chamber. I will come to the bursary later.

Actually, I will come to that part of my speech now as the hon. Member for Lincoln (Karen Lee) has mentioned it. I was one of the MPs who signed a cross-party letter requesting a royal commission for the 70th year of the NHS, because I believe that although we do not have all the solutions, we should set the tone. That would help to open the door of opportunity for those who work in the NHS. I will come to the bursary, which I have already raised with the Minister; I asked him to look in particular at the impact on mature students. Podiatry in Plymouth, for example, will not be taught from September onwards. In the south west, where the incidences of diabetes and other vascular problems are significant, we need podiatrists, so that is a major problem. The reason given is that most people who go into podiatry do it later on in their careers, and one of the challenges arising from the removal of the bursary and introduction of student loans—I voted for that and regret doing so—is that those who take out the loan immediately lose all welfare and can no longer get housing benefit.

For someone with a young family who wants to study, the student loan, or the grant available for mature students, is just not enough. The Minister is aware of my view because I have raised it before, and there is work to do on that. It is not about financial incentives; it is about making it affordable for people to go and do a fantastic job. As the hon. Member for Wolverhampton South West rightly said, some people bring so much to health and social care and we need to ensure that we take away every possible barrier without creating unintended consequences. I am sure that the Minister will be pleased to address that point later.

I will talk briefly about how Cornwall is responding. I have been very keen to see what we can do in Cornwall to make sure that people can turn up, get training and work and train on the job. For people in Cornwall, most opportunities for training are outside the area, but as we know, people who go into some professions, including in the NHS, tend to stay where they train. That has always been a problem for Cornwall, which has struggled to recruit the people we need. We have set up a health and care academy using the apprenticeship levy. The academy can offer people training and jobs as healthcare assistants. There, they can do 12 hours per week working and studying through the Open University, and will become qualified nurses after four years. As they are already settled in the area and have family there, they are very likely to work for the NHS for the rest of their careers.

I get what the hon. Gentleman is saying, but I worked for 40 years in the health service and it was because I saw its deterioration that I came to Parliament to say, “This is what’s happening.”

I said that in humour, which is why I talked about my own skill—or lack of. It is a curious thing, though, to hear people talking about the crisis in staffing when so many of them are in this place.

On a more important note, we are in a tricky situation with the challenges around the apprenticeship levy. In Cornwall, we hope to train 200 nurses using the apprenticeship levy over the next two years—that would address the shortage—but we have to recognise that funding is needed and I know that the Minister is looking at that now.

Will the hon. Gentleman give way?

I will when I have finished this point. Whatever the solution, we must recognise the added pressure on existing staff.

On that point, it is all very well getting nurses into and through training, but in Northern Ireland the NHS is haemorrhaging nurses who are not leaving the profession, but going into agency work, getting paid two and a half times more than they were and working the hours that they want. Not only is workforce planning impossible when people can just work when they want, but we lose continuity of care in wards.

I appreciate that valuable intervention. I had a conversation with the former Secretary of State for Health about how, when the student loan was introduced, there might have been a way in which students had all their loan written off if they gave seven years’ service to the NHS. The advantage of that, to be honest, is that people who had done seven years after qualifying would probably have settled down by then, entered into a home purchase and perhaps had family, so they would have been, first, less likely to clear off to another country and, secondly, kind of tied into the NHS where they were.

In part, that addresses the problem the hon. Gentleman raises. Yesterday, I met a newly qualified nurse from the south-west who found that on Christmas day she was the leading NHS nurse, supported only by agency staff. That must stick in the back of NHS staff’s throat, when they know that extra pay is available to agency staff. Efforts have been made to address that, and there must be ways to do so, but that is what we are getting at today—the workforce challenge.

If we have a workforce challenge, other things will happen, such as agencies springing up and the demand for them. We have to get to a place where working for the NHS as a nurse employed by the local trust is the best and most rewarding place to be, and appreciated by all. We simply do not say often enough how great such people are. We can do so many things locally and nationally to rebuild value, trust and appreciation in those people. The challenge for Health Education England is to look at how we fund local innovative ideas, ensuring there is enough money, as well as flexible support, to find solutions. I discussed that with Simon Stevens, and he seemed alert to the challenge.

As I said, I met nurses from the south-west yesterday, and they were concerned about safety on wards and retention of nurses. We have this bizarre circle spiralling downhill: if nurses do not feel safe, they go to do something that might not be nursing. Unfortunately, in places of low unemployment, lots of other work and employment opportunities are available, often paying more.

It is a pleasure to serve under your chairmanship, Mrs Moon. I thank my hon. Friend the Member for Wolverhampton South West (Eleanor Smith) for securing this important debate.

I will start by talking about my lived experience of staff shortages in the NHS. I worked as a nurse from 2003 until 2017, when I entered Parliament. For the majority of that time, I worked on an in-patient cardiac unit at Lincoln County Hospital. Today, I want to paint a picture of a nurse’s working day and how difficult that becomes when we have staff shortages. First, however, I pay tribute to all the staff at Lincoln County Hospital—not just the nurses, but all the staff—and to NHS staff who deliver our healthcare right across this country in local communities and in hospitals.

I keep in touch with my former colleagues and still hear at first hand how staff shortages affect them—some stories are quite scary. As an MP over the past two years, I have witnessed an awful lot of patronising pats on the back. I exclude today’s debate from that, but we often hear from Members how wonderful our NHS staff are, and yet that does nothing to address staff shortages or to make their working conditions any better. That is what they want; they do not want patronising pats on the back. The 40,000 nursing vacancies are evidence of that stark truth.

As a nurse, when I went on shift, I would be allocated eight cardiac patients. They would have been treated for heart failure, recently had a heart attack or been waiting for an angiogram, or perhaps they were being treated for endocarditis, which is a serious infection of the heart. The staffing was meant to ensure that a single nurse took either the male or the female team, with an extra nurse working between the two sides to support the multitude of tasks that delivering good patient care means. In reality, we often did not get that third nurse, and had to manage without. Some shifts felt like a marathon combined with a sprint—I kid you not, Mrs Moon, it really was that bad. I did love it though.

The medical management of my group of patients would be varied. Many patients were diabetics, meaning that we had to check blood sugars, four times a day for some and twice for others. If four or five out of eight of a nurse’s patients were diabetics, that was quite a task. We could even get something called “sliding scale”, which meant we had to check them every two hours. Sometimes, honestly, we just chased our tail the whole day.

Many patients needed intravenous antibiotics, which were really time-consuming to prepare, even more so if a patient had a line, a Hickman or a PIC—a peripherally inserted central catheter—because it had to be done aseptically; it just took ages, and the nurse was running around the whole time. As well as that, staffing was routinely topped up with bank or agency staff. I am not knocking them, because we would not have managed without them, but they were not allowed to do IVs, so when we had agency staff on the other side of ward, to be honest we would end up doing quite a proportion of their work as well. That made it really difficult.

It is a pleasure to serve under your chairmanship, Mrs Moon. I congratulate the hon. Members for Wolverhampton South West (Eleanor Smith), for Lincoln (Karen Lee) and for St Ives (Derek Thomas) on their eloquent speeches.

The crisis in the NHS workforce is deeply concerning. Its effects are felt nationally, locally and personally. Like others here, I want to pay tribute to the people working at every level of my national health service within the south lakes: the hospital in Kendal, Westmoreland General Hospital, and the district generals that we travel to in Barrow and in Lancaster. Of course, there are the GPs, dentists, paramedics and those providing mental health services. They do an outstanding job, but it is particularly challenging in rural areas, where we have specific problems with workforce planning and supply, which are at the heart of the problems that we are challenged by.

There are several key elements to workforce planning, including accessible and high quality training, as well as affordable training, as has just been mentioned so eloquently. Effective recruitment is another. Alongside both of those is the issue of staff retention. The Secretary of State must surely be held to account for each of those. The huge shortages in the NHS workforce are felt heavily in numerous areas of healthcare provision in the local communities in Cumbria, and I briefly want to touch on a few of them.

The provision of ambulances and ambulance crews has been hit particularly hard. It is vital that we recruit and deploy more paramedics and ambulance technicians. Rural communities such as mine suffer because of the sheer distances that ambulances have to travel to reach patients. According to the review of NHS access standards, it is the responsibility of ambulance trusts to respond to category 1 calls within seven minutes on average. That is a tall order when there are half the number of ambulances per head in the north-west of England as there are in London, despite the fact that my constituency alone is bigger than the whole of Greater London. It leaves communities living in fear for their safety and takes a serious toll on the physical and mental health of our outstanding ambulance crews. Our local paramedics and ambulance technicians are being pushed beyond their capacity. As a result, I have had an influx of local people contacting me about having to wait hours for an ambulance to arrive to give them the treatment that they so desperately need. That is why local health campaigners have been calling on the Government to deliver two new fully crewed ambulances to south Lakeland to stem the crisis and ensure the safety of the community. It is not right that people in Grasmere, Dent or Hawkshead might be an hour away from the nearest available ambulance.