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Health and Social Care

Volume 776: debated on Thursday 24 November 2016

Motion to Take Note

Moved by

To move that this House takes note of the implications for the health and social care workforce of the result of the referendum on the United Kingdom’s membership of the European Union.

My Lords, I am grateful to have been able to secure this debate. I will use the term EU collectively to cover the non-UK parts of the European Union and the European Economic Area, as only 230 health and social care staff come from the latter.

We spend about the same percentage of our GDP on publicly funded health as is spent on average by the 14 nations who acceded to the EU before 2004, yet an Organisation for Economic Co-operation and Development report published today shows that we are the sick man of Europe for doctors and beds. Our heart attack and stroke survival is mediocre, cancer survival poor, we desperately need more doctors—Germany has 50% more than us—and we need more, not fewer, beds.

Our struggling health and social care sector has unfilled posts, increased demand and funding pressures. Until now, reciprocity of qualifications and free movement has brought us Europeans, from the top-flight academics and clinicians with unique skills to the lowest-grade care workers. Now, with Brexit, we must decide what we want to negotiate for.

Twenty-nine major health and social care professional bodies, royal colleges, unions, employers and skills and learning organisations have formed the Cavendish Coalition to ensure a sustainable workforce supply and thereby maintain excellent standards of care.

Around 160,000 current NHS and social care staff are EU nationals—58,000 in the NHS and 90,000 in social care, which is 6% and 7% of the workforce respectively. Most are in posts that would otherwise have gone unfilled; they are essential to sustaining services and to our research enterprise. Unless we respect staff at every level and the NHS and social care become good employers, we will not attract the next generation here into the care sector.

Salary alone is not a proxy for worth. “Worth” is knowing that you are valued in society and respected as doing an important, complex and at times difficult job because you have unique skills. After Luxembourg, the UK is the largest net importer of healthcare professionals who qualified in other parts of the EU, particularly in some specialist NHS trusts such as the Royal Brompton and Harefield, where more than 15% of staff are from the EU.

Let me start with my own profession, doctors, of whom a quarter overall are non-UK graduates. Some 11% of registered doctors in the UK—just over 30,000—gained their primary medical qualification in another European country. That is one in 10 of our NHS doctors. We are so under-doctored that 40% of advertised consultant vacancies are unfilled, usually through lack of suitable applicants. Well over a quarter of current consultants report,

“significant gaps in the trainees’ rotas such that patient care is compromised”.

The very welcome increase of 1,500 medical student places will take a decade or more to feed through to supply specialists. In the meantime, we must continue to recruit from outside.

What about beyond medicine? Overall, the NHS vacancy factor is running at 6%, particularly in nursing. Almost a fifth of midwives in parts of London—it is 6% across the UK—are EU nationals. We rely on Europe. There is already a tension between safe levels of nursing staff and financial pressures against using agency staff. I know my noble friend Lady Watkins will address the nursing workforce further. Access to dentistry is also already a problem but I will not the steal the thunder of the noble Lord, Lord Colwyn. We rely on physiotherapists from overseas, 7% of whom are EU qualified. As service demand grows, so recruitment becomes more difficult. The Chartered Society of Physiotherapy—I declare my interest as president—has workforce modelling showing we need at least 500 extra physio student places each year for the next three years.

In social care, one in 20 social workers and more than one in 10 other professionals, particularly nurses, are from the EU, but the greatest crisis looms in domiciliary social care. Turnover rates are already incredibly high: currently well over one in three, 37%, leave their role each year. This churn leads to lack of continuity and concomitant problems. When will the current workforce be told they have indefinite leave to remain—with their children? We cannot continue to defer such assurance which must apply regardless of how long they have been in the UK.

This workforce provides care and support to aid people’s independence, and prevent ill health and unnecessary hospital admission. They care for people when they are most vulnerable. The mood music is positive but that is not enough. These people we depend on need legal certainty and we need that clarified quickly to mitigate the risk of staff leaving. Such rights, including any cut-off period post-Brexit, must be communicated in a way that actively supports community cohesion and reverses the detestable aggressive and xenophobic attitude seen in recent months. If EU workers continue to feel unwelcome and decide to leave, some NHS and social care services will simply have to put up a closed sign.

On staff numbers, I focused on the large number of EU nationals working here in health and social care but more than double that number are non-UK, non-EU staff. Blanket calls for tighter immigration controls overall will simply cripple NHS and social care at a stroke. Make no mistake: the current five-year rule for a permanent UK residence card would exclude thousands. More than a quarter of all adult social care workers are from outside the UK.

The current tier 2 visa system needs review. With a fixed quota of tier 2 work permits, applicants score more points for higher-paid jobs; it is not a level playing field. Financial services staff enter in preference to low-paid health and social care staff, yet we desperately need the latter. Will the Government undertake to urgently revise both the residence requirement and the tier 2 visa points for future health and social care staff?

We must continue to recruit and retain health and social care staff from the EU and beyond while we try to increase domestic supply. To fill vacancies, more specific occupations than just nurses and midwives need to be added to the Migration Advisory Committee’s shortage list. Yet a word of caution: we must not compensate for fewer Europeans by selfishly raiding professionals from developing countries. That would further destabilise our world.

The Medical Training Initiative is a mutually beneficial scheme, run by the Academy of Medical Royal Colleges. It gives junior doctors from all over the world the opportunity to work and train here under a tier 5 visa while giving trusts a high-quality, longer-term alternative to locums for filling rota gaps. Will the Government support extension of this proven effective scheme?

We need special arrangements for Ireland. Professionals flow freely between north and south across the land border. Many doctors in Northern Ireland graduated from a university in Eire. Are the Government looking to Ireland to be our friend at the table when we leave the EU, in the same way that Norway relies on Denmark?

In employment policy and practice we benefit from remaining in concert with Europe, not disconnected from advances that safeguard staff such as TUPE protection during service reconfigurations and the manual handling directive. The European working time directive is in UK law and junior doctors’ working hours now average 48 a week. No one should contemplate increasing hours post-Brexit but we could introduce more flexibility over rest breaks and work patterns to enhance work/life balance and improve training. This can be done if and only if there is no tightening of immigration numbers in health and social care.

The General Medical Council would like the opportunity to test the competence of all doctors coming to practise here from Europe, to check they meet the same standards as UK graduates and so better protect patients. To make this possible, will the UK Government amend the GMC’s powers as set out in the Medical Act 1983? Will regulation and training across professions be integral to Brexit negotiations?

Currently, medical and research staff particularly benefit from training experience in EU countries. Will the Government remember to keep the door open for UK doctors wishing to work in the EU once the UK is no longer a member state? It is not only doctors but nurses, physiotherapists and all our other professionals.

Let us not forget biomedical research, in which we have been a world leader. Our global collaborations keep us ahead of the field. To date, the UK has been a net beneficiary of European research funding. From 2007 to 2013, we received €8.8 billion but contributed only €5.4 billion. The Prime Minister’s announcement this week of an extra £2 billion research development spend is incredibly welcome but we need to be able to employ the right talent to optimise research output.

Overall, one in five of the UK’s academic community is an EU national, although more than three-quarters of the winners of the prestigious BMA medical research grants this year originate from other European countries. Brexit risks our being excluded from the Erasmus and Marie Curie research training schemes and from invaluable collaborative experience in communicable disease management at the European Centre for Disease Prevention and Control. We cannot exclude ourselves from this expertise. Infection and toxins know no political barriers. World epidemics are and will remain a looming threat to our nation’s health.

The impact of Brexit, with falling scientific recruitment and disrupted Horizon 2020 research, was reported in Nature in August. Is the Government’s plan that we try to remain part of EU research systems and contribute funds to the European grants schemes so that we can apply for them? Will the Government ensure that our future regulatory framework enables cross-border research and clinical trials, even though we may well wish to be more nimble in the newer research fields, such as genomics?

The challenges are huge. To grow our own we must attract people into health and social care. That means valuing staff at every level, both in the workplace and in society, for the complex job they do and the personal risks to which they are very often exposed. Society’s attitudes to the sick, the vulnerable and the frail must change, and those who care for them should have proper working conditions—not thanklessly be worked into the ground. Only then will we attract our school leavers into caring roles and only then do we stand a chance of being self-sufficient in health and social care. I beg to move.

My Lords, I am sure noble Lords will be grateful to the noble Baroness, Lady Finlay, for giving the House another opportunity to examine the reaction to the result of the referendum on the UK’s membership of the EU, particularly with regard to the health and social care workforce. I am looking forward to hearing from noble Lords, some of whom contributed to the debate introduced by the noble Baroness, Lady Watkins, on 21 July. I am not used to speaking at such a high position on the list and the noble Baroness is probably not used to speaking near the end, but I am sure we are all grateful to the noble Baroness, Lady Finlay, for securing this debate.

I will refer to the situation in the workforce and the implications the result of the EU referendum might have for doctors, nurses and other health professionals, as well as social care workers. I take this opportunity to highlight the fact that Britain’s exit from the EU is likely also to have a major impact on Britain’s fourth-largest healthcare workforce group: the dental professionals. My noble friend the Minister will be pleased that, like the noble Baroness, Lady Finlay, I have managed to refer to my own profession. I declare my interest as a fully retired dental surgeon, a fellow of the British Dental Association and vice-president of the British Fluoridation Society.

Of the 40,000 dentists registered to practise in the UK, close to 7,000 qualified in one of the EU countries outside Britain. Many of them relocated here in the early noughties in response to the well-publicised shortage of NHS dentists at the time, and there is absolutely no doubt that they make a crucial contribution to dentistry in the UK, both in the NHS and in private practice. These dentists’ ability to work in our country is based on the European principle of free movement and the professional qualifications directive. It is of utmost importance that their rights to live, work and have their qualifications recognised here is retained post-Brexit. The failure to do so could lead to a significant workforce shortage in general dental practice and create severe problems with access to dental care for patients in many areas.

Issues with recruitment of dentists for high street practices are already surfacing again in quite a few areas, and I am very concerned that this trend might be aggravated by Britain’s anticipated exit from the EU. It is crucial that EU dental health professionals receive firm and unequivocal assurances that they will be able to continue to practise in the UK following Brexit. We cannot afford to keep them guessing. In fact, the British Dental Association has informed me that it has been receiving inquiries from members who are considering leaving the UK as a consequence of the uncertainty of their status in the wake of the referendum result.

It is all too easy to think that if there is a serious shortage of staff in dental practices as a result of Brexit, we could just plug the gap with dental professionals from outside the EEA, but that is not as simple as it might sound. Any dentist coming to the UK whose qualifications are not recognised under the European professional qualifications directive must sit the General Dental Council’s overseas registration examination. This examination, at over £3,000, is not only incredibly costly but it does not have a particularly high pass rate. Due to the high cost of its administration, it is not held very often, which means that it could take a dentist applying to sit the exam—assuming that they are successful the first time round—more than a year to pass it. Add to this the necessary visas and the lengthy process of equivalence dentists need to undergo in order to be allowed to work in the NHS and it becomes very clear that relying on dentists from outside the European Union to fill the gaps in our dental workforce would not be wise.

Finally, we should not forget that while dentists are first and foremost health professionals, most high street practices are effectively also small independent businesses. This makes many dentists business owners, who invest in and develop their practices through their income and borrowing. Their business running costs are affected by inflation and given that a large proportion of their equipment and materials is imported, they will also be hit by the falling value of the pound.

A possible wider economic downturn that we might experience following Brexit could lead to a further drop in dental practices’ income. This is because many patients view oral healthcare as a discretionary cost—increasingly so in the context of ever-rising dental patient charges. If they need to tighten their belts, many will opt out of visiting their dentist, even if this is detrimental to their oral health. Any such drop in practice income could mean practice owners having to let go of some of their staff or possibly even compromise the financial viability of the entire practice and lead to its closure, leading to potential problems with access for patients who need dental help.

I would be very grateful for the Minister’s assurances that all dentists qualified in one of the countries of the European Economic Area will continue to have their qualifications recognised in the UK post-Brexit, and will be able to continue working in our dental services and serving British patients.

My Lords, this is the second Thursday in a month in which the House has focused on the potential downsides of Brexit. Last time we were talking about higher education, and now it is health and social care. There are many other subjects of a similar nature that we could debate. I am tempted to suggest that we run the whole series and at the end of it cock a snook at the popular press by publishing a little account of the debates called “Why the British People Was Wrong”.

I will concentrate my remarks on social care. Of course, the health and social care workforces overlap. There are nurses who work in the health service, nurses who staff nursing homes and nurses who work in the community, although health workforce planning seems to ignore the fact that there is a need for nurses elsewhere. But social care is different from health in one particular regard: most of it is not provided by people who were trained for years and years to do so. Of course, there are very important skills required of people in the social care sector but most—not all—can be acquired in relatively short periods. That makes a big difference to planning.

What will be the impact of Brexit on the social care workforce? We do not know. We do know that nationally 6% of social care workers come from the European Union; that rises to 12% in London. Will they be available in future? Well, that depends on two known unknowns. The first is whether the Government eventually accede to the soft-Brexit option of continuing with free movement of labour. Secondly, and if they do not, is how they decide to prioritise two of their objectives: keeping a healthy social care workforce by letting the workers in—or if they are already here, letting them stay—or keeping the immigration figures down. I fear that we will not get a clue this afternoon as to which of those options the Government will choose.

What we know as a certain fact is that the demand for such workers is going to rise. It will rise simply because of the demographics, as the number of old and very old people rises. We also know that there is much uncatered-for need at the moment. Research published last week by Age UK shows that, since 2010, nearly 400,000 more people aged over 65 are living with some level of unmet need, while the numbers getting care from local authorities in their own homes have fallen by something like 25% over the past four or five years.

I am an economist, so if this were about most industries, it would not cause me tremendous bother. If the supply of labour falls short of demand and need, the straightforward solution is to raise wages. In social care, that would have another great advantage: it would be some recognition of the real contribution that social care workers make. Unfortunately, there is a fatal Catch-22 in the higher wages logic: about half of old people in care homes are paid for by local authorities. Local authorities are also in high degree responsible for the care workers who look after people in their own homes. But consistently, year after year, the Government have forced councils to cut their spending so as not to have to cut their own. Defence’s 2% of GDP is sacrosanct; aid, as the House debated last Friday, must be 0.7% of GDP every year; health spending is protected in real terms. So the whole of the cuts falls on local authorities, and social care is overwhelmingly the biggest thing on which they spend money.

Council spending has been slashed by eye-watering amounts. There have been little handouts here and there, as the Minister will remind us. Councils are now able to increase their precepts by 2% a year to meet their costs although, of course, that greatly favours those areas with a lot of richly expensive residential housing and gives least to those areas which have less expensive residential housing—which of course are the areas where the greatest need for social care provided by the state exists. This is just one of several sticking-plasters being applied to a gaping wound.

Ministers claim that there is not unlimited money, and they are right. But are they using the money they have right? I want to draw the House’s attention to one rather shocking example. Recently, virtually unnoticed by the public, the press and Parliament, the Government increased spending on an area of social care in an expensive way by increasing the nursing care allowance. Now, to a degree, I contradict myself here, because the nursing care allowance—a non-means-tested payment towards the costs of those with substantial nursing needs who self-fund their care—was a recommendation of the minority report of the 1999 royal commission, signed by Lord Joffe and myself. Just as the British people was wrong, we was wrong about that. It has been a great waste of money.

I must also make a confession. If the Government had acted on my advice, I would be worse off, because I found the other day that I was the beneficiary of a handsome cheque paid from my mother’s estate. The money came from the Government and was the backdated value of the new allowance, which rose from £112 a week to £156.25, and covered the period from April to July, when she sadly died. I am not an extremely rich man, but anybody who thinks that I am in the greatest need of government benefits of this kind is really barking up the wrong tree. We are not the top priority. The top priority is those in the bottom half of the income distribution who need this care most and are being deprived of it. We found yesterday in the Autumn Statement that there was little money for the much talked-about JAMs, but there appears to be plenty of money for jammy sods like me. This preposterous propriety comes at a cost—wait for it—of £190 million a year. The Government are now looking at increasing the money still further. I have a great admiration for the Minister, but I am surprised that he can hold his head up in the face of these facts.

To sum up, in social care only two alternatives can be contemplated. One is to ensure that Brexit does not cut the social care workforce by allowing people who come now to come. The other is to fund social care more fully so that providers can afford to pay what it takes to attract the workers they need. Otherwise, and of necessity, we will end up in a position to which we are already heading at a rate of knots—that the welfare state, in so far as it looks after the old and needy, effectively ceases to exist.

My Lords, I am sure we all feel enormous gratitude to the noble Baroness, Lady Finlay of Llandaff, for introducing and leading this debate because she is one of the great experts in this House on the subject, particularly in covering doctors. I look forward to hearing from other expert voices, too, in this important debate and I thank the noble Lord, Lord Colwyn, for his wise words on the problems and dilemmas facing the dentists. My remarks may be more general because of my lack of specific, detailed expertise in the various medical and social care fields being discussed. None the less, that in no way reduces the anxieties of lay observers of the scene, such as myself, over what will happen in the dilemma now facing our medical and social care services as a result of the decision made by the people in June.

As the noble Lord, Lord Lipsey, implied, as time goes on we seem in the Lords to have more and more debates on Brexit and its consequences on different sectors and in general terms. They are having them in the Commons as well, thank goodness, but ours may be more numerous. Next Thursday there will be another debate here about the agonising dilemmas of Brexit. We face a grotesque, difficult and almost unassailable situation with what happened at the end of June and the Government’s attempts—I feel sorry for the Minister, who is directly involved, and for the Prime Minister—to deal with these huge and sometimes insoluble dilemmas.

All the time, we are approaching that horrible date when Article 50 will launch the actual negotiations. This will be some time in March, according to the Government’s latest pronouncement. I have tabled a Question for 19 December asking whether they might kindly give an exact date by then, but maybe that will be too early. Until that date comes this is really a phoney war in one sense, but one of the greatest importance as the doubts and second thoughts begin to develop. They are at very early levels. I have tremendous respect for the people’s decision on 23 June—that is of course axiomatic for all right-thinking parliamentarians of both Houses—but there are indications that second thoughts and doubts are beginning to creep in.

I refer particularly to the excellent submissions we have had from the medical field in preparing for this debate. In the time available, I should like to quote from the briefing that the BMA sent us in some detail. Page 2 of that briefing says:

“It is important to acknowledge the contribution made by European migrants, including doctors, in delivering and sustaining public services, such as the NHS, care services, and our universities. Doctors from the EU have become essential members of the UK’s medial workforce and the NHS is dependent on them to provide a high quality, reliable and safe service to patients. These highly skilled professional have enhanced the UK health system over the years, improving the diversity of the profession to reflect a changing population, bringing great skill and expertise to the NHS and filling shortages in specialties which may otherwise have been unable to cope. We unreservedly condemn the xenophobic attacks by individuals who have taken the referendum result as a green light to attack the NHS staff who care for them”.

I wholeheartedly endorse that, as I think others will.

The dark forces unleashed by the elements in that decision which are not the general elements of a generous population in the British political system in normal times have to be taken into account as time goes on. It will not be easy. I am grateful that the noble Lord, Lord Turnberg, and the noble Baroness, Lady Walmsley, who are experts in these fields, are on the Opposition Benches to guide us along these difficult paths. If NHS employees and professionals from the EU, the EEA and non-European areas are excluded from the results of negotiations which are not very successful after all, that would be a calamitous decision for this country in every way.

All the Ministers on the Government Front Bench are good listeners, but the noble Lord, Lord Prior, is one of the best. I am sure he will be kind enough to respond at the end of the debate if I ask him two direct questions. First, what guarantee will the Minister give that EU citizens currently working in the UK—there are 90,000 in social care alone—will have their right to live and work in the country maintained after the UK leaves the European Union? That applies, of course, to other people. Secondly, will the Minister make maintaining mutual recognition of medical and social care certificates a red-line issue for Brexit negotiations? Not much has been said so far, apart from some vague allusions to the subject and some hints here and there, in a very disconcerting and disorganised way, so we need that guidance.

Things are going to get worse as time goes on and as the public begin to manifest second thoughts, to which I have referred, about this whole, unhappy, nightmare business of trying to negotiate leaving the European Union. Most people in this country increasingly realise that we do not need to leave the European Union to maintain a figment of imagined sovereignty that probably last existed in this country and in other countries in about 1912. Even then, a few years later, British Armed Forces were under the control of a French commander-in-chief in the First World War.

So many letters and emails are now pouring in, grumbling about what happened at the end of June and asking what parliamentarians are going to do about it. I shall quote just one of them. I shall not give the name of the person who wrote it because I have not had time to contact him in order to do so. He writes: “We must assume that this is an irreversible notice, yet these are the issues. Sixty-three per cent of the electorate did not chose to leave the EU in the referendum. This Government is proud of running the country, but it does it on the basis of 24% of the population, the lowest figure in the post-war period. In Europe, that cannot be other than a minority Government. Of the 37% who chose leave within the binary option available, how can we know that they intended a hard Brexit? Even the top leave campaigners have rejected that possibility more and more rapidly from now on. I know it is difficult to believe this, but even Nigel Farage has admitted that he knew that the referendum was and is advisory only. Finally, Brexit campaigners have created a dangerously toxic EU debate where facts do not matter”.

That is just one example of the letters and emails that are beginning to pour in. I believe that the national petition has now been signed by well over 4 million people and that number will grow as time goes on. There may be plenty of time for these negotiations, but if they get plenty of time for sensible decisions to save this country in the future, I for one—not only for medical and social care reasons—will be deeply grateful.

My Lords, I thank and congratulate my noble friend Lady Finlay of Llandaff on securing this very important debate. I hope it will highlight the essential need to be able to fill some of the gaps in our NHS and social care workforce with people who come from Europe and elsewhere. There are gaps too in the private sector, and disabled and elderly people living in the community in their own homes are also having difficulties. As it is now, with the extreme demands on the services to fill the gaps, if we are more restricted, it will be a total disaster.

Nobody knows when they or their families will need the NHS. It can be the vital lifeline in an accident or serious illness. Since the campaign and the referendum, there has been an increase in horrible incidents involving people who seem not to be British or who support the EU. The tragic murder of Jo Cox MP has shocked the world, as has the murder of a Polish man. Given the uncertainty of what will happen when we leave the EU, recruitment has already become more difficult for the health and social care workforce. If people who want to come to work in the UK feel they are not wanted and are not safe, they will go elsewhere. There are plenty of other countries in Europe which need them apart from us. It is of great concern to hear that the Commons Health Select Committee has criticised some hospital trusts for allowing poor performance to “become the norm” in A&E departments because of the lack of staff. The NHS faces a winter predicted to be more difficult than the last. What preparations are being made for this crisis?

More than 55,000 EU nationals work as doctors and nurses in the health service, which would collapse without them. Companies that recruit abroad on behalf of NHS trusts are full of anxiety. TFS Healthcare, which recruits nurses for UK hospitals from Spain, Portugal, Romania, Poland and Italy, is already seeing the impact of the Brexit vote. A lot of nurses from these countries have now been put off coming to the UK. The managing director says that even more concerning is that nurses already placed in UK hospitals are seriously considering leaving as they no longer feel wanted or welcomed. The BMA has warned that the boost in home-grown doctor numbers will go only part of the way to addressing the NHS recruitment crisis.

I cannot stress enough how serious the problem is becoming because of the escalating costs of agencies. Those who work for agencies charge so much that people with disabilities living in the community find it difficult to fund their care, and local authorities find it difficult to fund care for the people they support. As a result of cuts and growing costs, social services have reached crisis point. With society getting older, people having complex conditions, and NHS and care staff also getting older and retiring, we need young, fit, honest people, and we should welcome them coming from abroad to fill shortages in our NHS workforce.

There are exciting advances in personalised treatment across the world. The UK is among the leaders in the field in Europe, and it is important that people in Europe do research work together and share data. If we lose our place in Europe, it would be everyone’s loss. In research, everyone should work in co-operation with the universities to drive innovation forward. What will happen when we lose the grants from the EU? Will other grants be available? Perhaps the Minister can answer that.

Many people in the healthcare system fear that the UK’s decision to leave the EU could result in the repeal of various regulations, including many implemented through directives designed to protect the rights of workers. Regulations also need to be correct for the safety of patients. The Medicines and Healthcare Products Regulatory Agency, the MHRA, has been very important to both the UK and Europe; whatever happens due to Brexit, I hope it will continue to play an important part in their work.

I hope the Government realise that morale among the healthcare profession is at an all-time low due to the many pressures on it. I hope this debate may make decision-makers realise that more support is vital, and that the NHS and social services must have the workforce they need to make it a safe and thriving service.

My Lords, I am grateful to the noble Baroness, Lady Finlay, for bringing this important matter before the House today. The right reverend Prelate the Bishop of Carlisle, our lead bishop on health and social care, cannot be in his place today, but I am glad to contribute from these Benches on his behalf.

The debate brings to mind two principles central to Christian faith and practice: justice for the stranger in our midst and care for the vulnerable. Mosaic law enjoins us not to withhold justice from the outsider. Only yesterday, in conversation, the Secretary of State for Communities and Local Government sought to check that I had heard the words of Jesus, “Love thy neighbour as thyself”. I am grateful to him. This reminds us that the words of Jesus tell us that every care and service given to others is a service given to God.

In the context of the present debate, I want to explore how those principles might be applied to care workers. I trust that the first of these will be upheld in line with the Government’s statement, recorded in the Guardian on 21 September, that the Prime Minister has been clear that she wants to protect the status of EU nationals already living here. In excess of 84,000 EU citizens do the demanding and essential job of caring for vulnerable people in our society, day in, day out. They deserve both our gratitude and support. For their sake, as well as the sake of those they care for, I trust they will continue to be welcome.

As we all know, social care in this country faces a challenging future. Only last week, Age UK and the Alzheimer’s Society reported that some 300,000-plus elderly people are in need of social care but are not receiving any assistance; indeed, my own mother is one of these. With an ageing population, this problem is likely to get worse unless the recruitment of care workers increases notably. It is difficult to see how this can be achieved if immigration policy is changed post-Brexit. According to modelling by the charities Independent Age and the International Longevity Centre UK, if all immigration from the EU were halted there would be a shortage of care workers in excess of 1 million by 2037. A low-migration scenario would still mean a 750,000 shortfall. Even under current migration conditions, the care sector will face a workforce shortage of 350,000 because of the likely dramatic increase in the population needing care.

I cannot stress or praise highly enough the role played by care workers, whether in care homes or through domiciliary care. Care workers play an indispensable role in promoting the health and well-being of millions, mostly elderly or disabled people. Without their intervention, the needs of many vulnerable people would go unmet. Some might go for days on end without any meaningful contact with their families or other human beings. The economic cost to the nation would be immense.

In the past I have been a trustee of a Christian care home and domiciliary care service, and I have seen at first hand the extraordinary work undertaken by care workers over and above what they are paid to do. In spite of that, care workers are seldom given the recognition they deserve, with few attempts being made to make care work a recognised and valued profession. It is therefore no surprise that there is a growing shortfall in the number of care workers from within the resident UK population. Unless underlying issues are addressed, the disparity between care provision and need will continue to grow even if Brexit’s efforts prove to be less damaging than many fear.

The UK care sector is indebted to EU workers, in part because it is difficult to recruit and retain care workers from the existing population, given the poor wages, inadequate training and low esteem in which many care workers perceive themselves to be held. The jobs of current care workers from the EU ought not to be at risk if the Prime Minister’s undertaking is adhered to, but it is really important that the UK does not continue to rely on EU workers solely because care work is attributed such a low status. The pathway to sustaining and developing the care workforce lies in improving the profession, rather than relying on others to do the jobs that many UK citizens are not prepared to do.

The Social Care Institute for Excellence, in its Dignity for Care Workers initiative, set out a series of recommendations for commissioners and providers of social care that would enable workers to enjoy the esteem in which they deserve to be held. These go beyond addressing the persistent problems of low pay and zero-hours contracts, calling on commissioners and providers to offer support and training, proper career pathways and the involvement of care workers in day-to-day decision-making and service improvement.

It is essential that Her Majesty’s Government take effective action to address the concerns of care workers, rather than continuing to rely on low-paid, unqualified positions that offer little job security or chance of advancement. Providing care for an ageing population requires a professional care force that enjoys decent pay, job satisfaction and prospects for personal and career advancement. The current question of admission of care workers from the EU ought not to mask these crucial concerns.

My Lords, I am sure that we are all grateful to my noble friend Lady Finlay for securing this debate on an issue which has not had the public attention it merits. I say at the outset that I am a remainer who believes we made a massive error of collective judgment on 23 June. However, whatever your views on Brexit, the NHS and social care sectors now face a very uncertain future if they are prevented from recruiting at scale from both within and outside the EU. Far from releasing resources for the NHS, as the more excitable Brexiteers claimed, Brexit is likely to damage our health and care systems in terms of both funding and workforce. It is the latter we are discussing today, rather than the funding consequences of the £60 billion upfront costs of Brexit that the OBR has estimated.

We do not start from a good position for handling the Brexit challenge for our health and care sectors. These are very labour-intensive industries, where about two-thirds of their costs are labour and service demand is growing rapidly—at a rate of at least 4% a year for the foreseeable future. They will need more people of some kind for years ahead. Successive Governments have failed to deliver effective long-term workforce plans. Health Secretaries usually aspire to greater workforce self-sufficiency but fail to stick to the policies and plans that would achieve it. We as a country have become obsessed with avoiding oversupply of the workforce. The result has been that the health and care system never produces the doctors, nurses, other professionals and care workers that it needs for the future. It has also been lacklustre at retaining and upskilling the workforce that it has. Even now, we are cutting education and training budgets to deal with acute hospital overspends. We have a serious addictive habit of relying on recruitment from overseas to plug our workforce gaps. About 280,000 doctors are registered with the GMC, and about a third are foreign-trained, with 30,000 trained in the EU. About 10% to 12% of the foreign-trained doctors are specialists.

Only this week, the Royal College of Surgeons told this House’s Select Committee on the Long-Term Sustainability of the NHS, of which I am a member, that 40% of surgeons on the specialist register were trained overseas—about half of them from the EU. The Royal College of Physicians told us that its figure was 20%. Shortage specialties such as radiology cannot cope without overseas recruitment. A very high proportion of patient diagnoses, especially for cancer, depend on radiologists interpreting scans. I gather that about 250,000 scans are awaiting interpretation, yet there is a 9% vacancy rate for radiologists, with about 40% of those posts remaining unfilled for more than a year. Radiographers cannot help much, because their vacancy rate is even higher. This specialty will continue to be dependent on the recruitment of overseas radiologists and radiographers for as far ahead as we can see.

It is not just overseas doctors we depend on. The NHS has to compete in a total pool of 90,000 registered nurses who were trained overseas, and secures about two-thirds of them—about one in seven NHS nurses. There are also about 15,000 other NHS staff from overseas, nearly half of whom come from the EU. The picture in social care is similar, with about 30% of the professional workforce coming from overseas, and just over a third of those coming from the EU. Approaching 20% of the total social care workforce comes from overseas.

Some parts of the country are more dependent on overseas staff than others. In London, about 40% of the adult social care workforce comes from overseas. The former chief executive of Addenbrooke’s—ironically, an Australian—has said that about a third of its nurses are from overseas. Recruitment is going on from everywhere within the EU: radiologists from Latvia, Hungary and Greece; paramedics for ambulance trusts from Poland; nurses from Italy, Portugal and Spain; doctors from almost anywhere, providing they meet the requirements of the GMC. The health and care system is now so dependent on overseas recruitment that it is difficult to see where plan B is, should access to overseas skills be closed—either by design or by sheer neglect.

By one of life’s splendid ironies, some of the areas that voted most emphatically for Brexit have the greatest dependency on overseas recruitment, with little immediate prospect of Brits filling the gaps. Fans of Tennessee Williams, like me, may remember the fading southern belle Blanche Dubois in “A Streetcar Named Desire” saying that she had become dependent on the kindness of strangers—I will not do the accent. That describes the position of large parts of our health and care system, as we face the rather unappetising prospect of a shambolic Brexit.

In conclusion, I say to the Minister that the Government need to work much harder than they have done so far to convince both overseas staff already working in health and care that we want them to stay and to reassure their potential successors that the Government will negotiate a Brexit that keeps an open door for them in a future immigration system. Controlling our borders should not mean shutting out the very people we desperately need to deliver NHS and care services to our citizens. Using these personnel as an EU negotiating chip will only drive them away and reduce the longer-term inward flow. We need to move on from the tautology that “Brexit means Brexit” and articulate a plan for safeguarding the essential workforce until we can be more self-sufficient, which cannot be before the 2030s.

Can the Minister enlighten us on what the Department of Health Brexit plans are for dealing with this issue, and is it working with the Home Office on visa arrangements that secure the health and care workers, both from the EU and from outside, whom we need for at least another two decades?

My Lords, I add my gratitude to that of other noble Lords to the noble Baroness, Lady Finlay, for nominating this debate on a vital matter. For me, it does not matter that we have debated this issue already this month; until the Government start to hear and understand the serious concerns, we shall be repeating it regularly.

Although most of my comments will be on social care, I want to start with a conversation I had with two nurses at St Thomas’ Hospital yesterday as I was leaving. They said to me, “You work over the road, don’t you?”. I said that I did, and they continued by saying, “We are just struggling to understand what on earth Brexit is all about. We knew during the campaign that that £350 million a week was not real, but we do not understand why people believed it”. Patients still talk to them about the extra money that the NHS is going to get. They said that they see crisis after crisis going on around them in what is an absolutely excellent hospital. I make no more comment than that, but it is clearly something that is troubling the workforce.

Others have commented on the size of the social care sector—a 1.3 million workforce. As other speakers have already outlined, struggling with the demography alone in Great Britain would put it under pressure, but it is facing a perfect storm. We need to add in the cuts to local government funding, the inability of the Government to commit to delivering Dilnot to really harmonise health and social care, and the Government’s relentless focus on reducing immigration. That is before we even start to consider the financial consequences of Brexit, as outlined yesterday by the OBR.

Independent Age and ILC UK research has looked specifically at social care workforce issues and their modelling shows that the closing off of migration will have a dramatic effect. There will be a social care workforce shortfall of 750,000 people if the Government achieve their objectives of only tens of thousands of immigrants into this country. Even under the high migration scenario, a shortfall of 350,000 is likely purely because of our ageing population. London and the south-east would be worst hit, because one in nine of the capital’s care workers are at risk of losing their right to work here.

There is a further problem in the sector of a very high turnover rate of around 25%, and an estimated vacancy rate of 5.4%, which rises to 7.7% in domiciliary care. The King’s Fund paper, Five Big Issues for Health and Social Care after the Brexit Vote notes that, immediately after the referendum,

“Bruce Keogh, NHS England’s Medical Director, and Jeremy Hunt, the Secretary of State for Health, have both publicly sought to reassure European staff working in the health service”.

They said:

“We endorse these views but would go further: providers of NHS and social care services should retain the ability to recruit staff from the EU when there are not enough resident workers to fill vacancies”.

Can the Minister provide encouragement not just to doctors, nurses and other clinical healthcare professionals but to those who absolutely fill the important jobs in the healthcare sector who have either low or no skills, such as healthcare assistants, cleaners and catering staff, so that they will also have the facility to come to work in the UK to provide vital services?

I turn to the specific experience of people in the social care system, which at the moment is really struggling with seven older people per care worker. By 2037, the projections show that that figure will almost double to 13.5 older people per care worker. That is very alarming, especially as we are relying on the care sector to relieve the pressure on hospitals. How on earth we expect the service to be able to be delivered with even fewer staff is quite extraordinary. London, as I have already mentioned, is especially reliant on migrant care workers. Nearly three out of five of its social care workforce were born abroad and, in recent years, the percentage of EEA workers has increased. Although the overall average does not look particularly large, EEA migrants now make up more than 80% of new entrants to the profession. With the turnover rates to which I have referred of one in four, the consequence of any restriction on EEA workers will be severe and rapid.

On the effect already of the pressures in the social care system, Age UK says that the number of older people in England who do not get the social care that they need now has soared to 1.2 million, up by 48% since 2010. Nearly one in eight older people are struggling with the help that they need to carry out everyday tasks, such as getting out of bed, going to the toilet, washing and getting dressed. Among that 1.2 million, nearly 700,000 do not get any help at all because, as we know, the moment there is pressure on services, the criteria for accessing help keep getting harder and harder.

My right honourable friend Norman Lamb has said that the health and social care systems are “living on borrowed time”, with more providers moving from publicly funded systems to focus entirely on private care. He said:

“The social care system always loses out in comparison with the NHS, and that’s the case even when the money was flowing”.

Under the later years of a Labour Government, there was a real disparity between the NHS and social care; in one Budget, the NHS was awarded 4% and social care just 1%. That is why the Liberal Democrats continue to call for a cross-party commission to address the problems of health and social care funding. We need to address that, and the impact of Brexit on both sectors.

The better care fund, in the coalition, was a small but helpful start, but it remains only a small contribution. Implementing Dilnot is urgent and overdue. Yesterday’s Autumn Statement failed completely to mention health and social care funding. The Alzheimer’s Society in its very helpful briefing made the very important point that, regardless of any changes in migration policies, the Government must make social care an attractive career pathway. Shortfalls in staffing are leading to social care providers failing. Already there is evidence, not just in the health and social care sector but more widely, that EU and EEA workers are leaving the UK because of the uncertainty following the referendum results. With a rapid turnover in the workforce, the consequences will be felt very quickly.

Finally, after all the doom and gloom, I wanted to end on one positive note about the diversity of social care staff. My mother, after one of her strokes, suddenly started speaking French—she had spent a lot of time in France in her childhood. The home went out of its way to find a French healthcare assistant to be moved to her ward and, as a result, she understood them and, importantly for her, someone understood her, and she was able to communicate easily. That is the social care system at its best. We need as a nation to understand that we have to resource it effectively to do its job; it cannot do it on thin air.

My Lords, as I have said before, the National Health Service is Britain’s national treasure, yet it is an institution that is constantly under challenge and pressure. It is the largest employer in the country and the sixth largest employer in the world. I thank the noble Baroness, Lady Finlay, for initiating the debate.

We have heard that there is a shortfall between the numbers of staff that the providers of healthcare services said that they needed and the number of posts, with huge gaps in nursing, midwifery and health workers. In 2014, there was a 50,000 shortfall, yet the Government continue to insist on this net immigration target, to bring it down to the tens of thousands. How will they achieve this when in the NHS and care sector alone, as we have heard, there are over 130,000 just from the EU alone?

We know that in 2015, the NHS recorded its largest deficit ever, of £2.4 billion. And yet, as the noble Baroness, Lady Brinton, has just said, there was no mention in the 72-page Autumn Statement document of the words “NHS”, “mental health”, “public health” or “social care”. May I ask the Minister why was the NHS missing from the Autumn Statement?

We know that the NHS needs more money; we spend less as a percentage of our GDP on health compared with many of our European Union counterparts. Of the original 15 EU countries, we are 13th in healthcare spending. There were some figures released today in the press. In terms of doctors per 1,000 people, we come 25th in the EU, with 2.8; the EU average is 3.5. For hospital beds per 1,000 people, we are 25th with 2.7; the EU average is 5.2 and Germany has 8.2. Our average maternity stay in days is 1.5; the EU average is 3.2. What does the Minister have to say about these rankings?

More than 30,000 doctors from the EEA are currently registered with the GMC to practise medicine in the UK. According to the Royal College of Paediatrics and Child Health,

“In paediatrics, 5.6% of consultants and 5.5% of speciality and associate specialist … grade doctors qualified in EU nations outside the UK … 30% of paediatric consultants and 45% of specialty and associate specialist grade doctors in the UK qualified from other non-EU overseas countries”.

I am chancellor of the University of Birmingham and we have one of the highest-rated medical schools in the country, and one of the largest—we take in almost 400 undergraduates per year. The Secretary of State has said that the Government’s intention is to introduce 1,500 new undergraduate medical school places to make the NHS in England self-sufficient by 2020. Are 1,500 new places going to make us self-sufficient? I do not think that that is possible. Can the Minister confirm that this is the reality?

The Royal College of Nursing, in talking about priorities, says that we have 33,000 EU-trained nurses. There are 58,823 staff with EU nationality working in NHS hospitals and community health services, of whom 10,000 are doctors, 22,000 are nurses and health visitors and 1,369 are midwives. One in three nurses is due to retire in the next 10 years. Clare Marx, the president of the Royal College of Surgeons, said that:

“Twenty-two per cent of registered surgeons trained in European countries, with a further 20 per cent from outside the EU … the main risk of any changes to migration rules is not to highly qualified medical professionals—which the Government has already pledged to protect—but to the tens of thousands of administrative, clerical, and support staff from overseas that the NHS and social care fundamentally rely on for delivery of the service”.

If you look at the statistics it is in every area: in medicine, 14% are from the EEA and 20% from the rest of the world; in something like obstetrics and gynaecology, 40% are non-EU and 15% are from the EEA—that is over 50%. That is how reliant we are on foreign staff and doctors in the NHS.

While we are waiting for Article 50 to be triggered, all our research funding is under threat, as was mentioned earlier. The thing about our research funding is that it is not enough for the Government to say that we are going to compensate for the lack of research funding because we will not be paying into the EU. It is the power of collaboration that we will lose. At the University of Birmingham we collaborated with the University of the Punjab, and during the Prime Minister’s recent visit to India we highlighted that when we do research on our own, the factor is about 1.6 and for the University of the Punjab it is about 1.3; when combined, it is 5.3. When we do combined research with Harvard University, it is 5.6. That is the power of collaborative research that we risk losing if we leave the EU. Higher education and research and the translation of that research into commercial breakthroughs and drug discoveries is huge. All that is under threat.

Elisabetta Zanon, the Director of the NHS European Office, said that:

“A prolonged economic fallout could indeed have a chilling effect on the NHS budget, which in turn could impact on patient care. It could potentially lead to longer waiting times, or reduced access to innovative, expensive medicines and health technologies, or in a lowering of quality”.

This is really serious. The scale of deficit, as we have heard, is up to £2.7 billion. The Institute of Public Care has forecast that the number of people aged over 65 who are unable to manage one or more self-care tasks will increase by 44% by 2030. Are 1,500 extra doctors going to cope with this? Eighty-four thousand of England’s social care workforce are EEA migrants. Head Medical, the largest UK-based international firm specialising in doctors, has said that overseas doctors are deciding not to work in the UK since the country voted to leave the EU, with an increase in the number of EU doctors rethinking their plan to come here. This is really serious.

When I was in India at the time of the Prime Minister’s visit there, she spoke of returning people from here to India. She did not mention higher education once. She did not even meet the 35 higher education leaders who were there with Jo Johnson at the time of the visit and did not even talk about international students. The Indian Prime Minister spoke about the importance and mobility of Indians and Indian students and of foreign education. I remind the House of the fear that arose when nurses who did not earn £35,000 within six years were going to be thrown out of the country. The public backlash was so strong that the Government rowed back on that.

Reducing migration will damage this country. The race and hate crime which I personally have experienced is absolutely shocking. I have met many people who voted to leave the European Union because they believed that slogan on the back of buses which said:

“We send the EU £350 million a week, let’s fund our NHS instead”,

and that hugely misleading Vote Leave campaign film which ended:

“Every week the UK pays £350 million to be part of the EU. That’s £350 million that could build one new hospital every week, £350 million that could be spent supporting our doctors and nurses. Now is your chance to take back control and spend our money on our priorities, like the NHS”.

Those were absolute lies. We contribute to the EU £150 million net a week, which is £8 billion a year. That is 1% of our government expenditure.

In conclusion, this debate is so serious and crucial because it is about the NHS and the care sector. However, it is also about immigration, our vital research, and about what lies at the heart of what makes this country so great, which is in threat and jeopardy.

I am delighted to follow the noble Lord and the trenchant points he has made. I thank the noble Baroness, Lady Finlay of Llandaff, for initiating this timely and far-reaching debate. I also take this opportunity to thank her for her tremendous contribution to the health and social care services in Wales over many years. She spoke today from a position of immense knowledge and experience. The Government would be foolish to ignore her warnings and, indeed, the warnings of others who have brought their expertise and viewpoints to this debate.

I wish to make it clear where I am coming from on this issue. I have always been an ardent European and regard the Brexit vote as an absolute tragedy. Therefore, before I address the specific healthcare dimension, I wish to say a word about the state of play on Brexit. I accept that, regrettably, we are likely to leave the EU. The vote on 23 June in the advisory referendum asks the Government to take such a step. The referendum did not in any way advise the Government on what new alternative relationship the UK should have with our current 27 European partners. Several alternatives were mooted during the referendum campaign by the Brexit backers. Some advocated a Norwegian-type relationship, some an arrangement more similar to that of Switzerland, and some even proposed Albania, Turkey or Ukraine as possible models. Others looked to the long-negotiated deal that Canada has secured. Others on the hard Brexit extreme advocated basing new arrangements on World Trade Organization rules, and essentially walking away from our European neighbours.

Not one of these alternatives was endorsed or rejected by the referendum. The Government have no mandate from either the referendum or the 2015 general election manifesto to adopt any of these alternatives as the way forward. They have not yet even asked Parliament to endorse any preferred course of action. Unless they secure a prior mandate from Parliament laying down the negotiating objectives—not necessarily in all the intricate detail, but by way of broad strategic targets—they must face the possibility two years down the line of returning with a set of proposals that Parliament then rejects. In these circumstances, Parliament would have every entitlement to instruct—yes, instruct—the Government to withdraw their Article 50 application, which lawyers now accept is legally possible. It therefore now behoves the Government to seek a mandate from Parliament for their strategic objectives, and I approach this debate on the potential implications for the NHS from that angle.

Improving, not undermining, the NHS was a serious factor which influenced many people to back Brexit, believing that the NHS would gain £350 million a week and thereby recruit more doctors and nurses, many of them from the European Union itself. The NHS is massively dependent on staff who have been recruited from overseas. Some 20% of the entire NHS workforce is from overseas: about half from the EU and half from other overseas countries. More than 10,000 NHS doctors come from other EU countries, as do more than 20,000 nurses, and they come predominantly from Ireland, Poland, Spain, Portugal and Italy. In Wales, a staggering 30% of all doctors were trained abroad—2,687 of them.

The Brexit vote has done two things. It has raised in the minds of NHS staff from other EU countries the question of whether they will be sent home when we quit the EU. These fears were exacerbated by the Prime Minister’s ill-advised comments at the Tory Party conference and her subsequent refusal to give assurances that all EU citizens currently working in the UK will, in all circumstances, be guaranteed the right to continue to work in the UK indefinitely. The only definitive statement made by the Prime Minister on these matters has been to rule out the Australian-style immigration system. The uncertainty created by the inept way the Prime Minister has dealt with these issues has led NHS staff, particularly in specialist jobs, to start looking around for suitable vacancies in other countries. No one can blame them. If in two years they find that they have to go, they might not then easily find a job in their home country. Indeed, they might face much greater pressure as other medical specialists in the UK also turn back to look for jobs at home.

The pressure to leave the UK is not just on EU-originated NHS workers. Many from Commonwealth countries have faced the horrid racial abuse that has mushroomed as a direct result of the Brexit campaign. Racially motivated crime has escalated, as the police have told us, and many NHS staff from non-EU countries are asking themselves whether they want to remain in a narrow, inward-looking, racially prejudiced Britain—indeed, whether they want to bring up their children in such a hostile climate. It is an absolute tragedy that all the hard work that has been done to break down the barriers of prejudice and racial hatred have been so disastrously undermined by the tone of the Brexit campaign, the outcome of the referendum and the Government’s inability to handle the situation.

I ask everyone, throughout the UK, to look around when they go to their hospitals and note the number of overseas workers on whose backs all that depends, and to look at the lists of names of doctors in the departments they visit and see the many names from foreign countries. My wife recently went to an NHS hospital in Wales, and of the 14 names on the plaque by the department no fewer than 12, at least ostensibly, were from overseas. I ask people to think what they would do if such staff went home, as some are told to do on the pavements of British cities. I ask them to consider the dependency of other services, such as home helps to support disabled people, or the staff in homes for the elderly who look after their parents or grandparents.

I ask the Government, taking all these aspects into consideration, to do three things. First, they should announce forthwith that every EU national—indeed, every overseas national—working in the UK will be entitled to remain here irrespective of the Article 50 negotiations and their outcome. Secondly, such a guarantee will have no ifs, no buts and no conditions; it will be absolute and not time-limited. Thirdly, it will be in the UK’s negotiating position, if we are leaving the EU, to retain our rights vis-à-vis the single market—if necessary, specifying a customs union deal—and accept the free movement of working people throughout the EU into the UK. Anything less than this will leave a bleeding wound that will hit many sectors of the UK economy, but none worse than health and social services, from which the haemorrhaging of vital staff could lead to the end of the NHS as we know it.

My Lords, I thank my noble friend Lady Finlay of Llandaff for securing this debate, which follows a similar one in my name held in July, referred to by the noble Lord, Lord Colwyn. I will not repeat a lot of what I said in July; instead, I shall focus on the challenges that have begun to emerge over the last three months in relation to nursing and the allied health professionals workforce.

Others have already said that it is vital that we continue to value our EU colleagues who work in the health and social care sectors. The Chief Nursing Officer, Jane Cummings, has joined others in stating the value that we place on these workers. At the moment, we can to some extent continue to recruit from the EU. However, as an example, on a recent visit to Spain it was made very clear to me by some nurses that they no longer seek an opportunity to come and work in the UK because they fear that the very high number of Spanish nurses who are here now will seek to return, and they may then not have jobs if they, in turn, go back to Spain after a short period here. So, as well as what we know from meta-analysis, we are, anecdotally, very clear that things are changing.

Another important point is that we must not over-recruit from countries where there is already a significant shortage of healthcare workers. The report of the noble Lord, Lord Crisp, which looks particularly at the triple impact of nursing internationally, argues that we must be very careful not to do that.

Amid the concerns and possible doom and gloom, this week the Royal College of Nursing celebrated its centenary and I attended part of its conference. A really positive note was the developments in nursing across the four countries of the UK and the absolute commitment to continuing to improve care and support for our communities, working with healthcare staff from a range of backgrounds and countries in the EU.

The UK Government have told us that they want to ensure that the health and social care needs of our population are not negatively impacted by the UK’s exit from the EU. A sound supply of staff is essential, not only for the NHS but for the voluntary and independent sectors. It is estimated, for example, that the independent health sector generates in excess of £2 billion a year for the London economy, with associated tax revenues for the Treasury. As indicated yesterday in the Autumn Statement, we need to keep this kind of business in the UK, and, to get those benefits, we need to provide the staff to deliver them.

Our relationship with the EU has had a substantial direct and indirect impact on the delivery of health and social care in the UK. It has developed really good patient safety standards and improved the quality of care. The staff we have now are central to the successful delivery of care in the future. Because so many others have talked about this today, I do not intend to dwell for long on the incredible support for older people that is provided by staff from the EU, However, it is essential that we develop more home-grown staff.

We need to develop a long-term, coherent workforce strategy and implement plans that maintain and grow the domestic health and social care workforce. The noble Lord, Lord Warner, talked very clearly about the fact that we have failed to do that in the past. There is a terrible fear of over-recruitment. Certainly we need a whole new set of doctors and nurses, but we also need nursing and medical academics to support the rapid increase in such programmes, so it is not quite as simple as it seems. We must ensure appropriate educational and professional regulatory frameworks, including for nurses, nurse associates and social workers trained in the UK, to create a proper professional pathway for young people.

Others have referred to the fact that a lot of the law from Europe has resulted in safeguarding decent working conditions for staff. It is imperative that as we go through the great repeal Bill, we do not undermine some of those advances, such as TUPE and other good standards for those employed.

I turn to the relatively severe concern of funding for the ongoing training of nurses, midwives and allied health professionals, which has been stripped out again this year. Therefore, we have people qualifying who would like to develop their career, but who cannot afford to because of the post-qualifying costs of further and higher education.

We have not seen any campaigns to successfully promote nursing as a career such as those we have recently seen for teaching. Of course, I finished writing my speech last night and then read the Metro on the way in this morning, in which there is a fantastic advert for nurses to return to practice in London—there are always exceptions to the rule. However, we need to fundamentally encourage people to come into nursing and the allied health professions, particularly as they will be starting to pay their own fees. We cannot do this too soon.

There are steps we can take that will protect against nurse shortages. Noble Lords will know that I have consistently argued that postgraduate pre-registration courses that supply nurses for the NHS need protection. I am delighted that the Government have committed to continue funding these in 2017-18, but that needs to continue until at least 2020.

My noble friend Lady Finlay described the numbers and challenges we will face if our EU friends decide to move. However, all the figures on NHS-funded nurses fail to take into account the shortage in specialties in mental health, largely because most of the child and adolescent mental health services are provided by private companies contracted by the NHS. There is already concern that recruiting to mental health and learning disability nursing programmes next year may prove difficult. We need to keep a watchful eye on this and ensure that we can retain and recruit in those areas.

Common EU standards for training and recognition of qualifications have enabled mobility, raised educational standards and improved health. Other activity, including research collaboration, has developed nursing practice. I trust that the Minister will give careful consideration to some of the challenges we have raised, particularly how we will staff mental health and learning disability services in the future.

My Lords, I, too, thank the noble Baroness, Lady Finlay of Llandaff, for introducing this debate. I note with interest that not one speaker thinks Brexit will be good for health and social care. The tragedy of the vote on 23 June—by 37% of the electorate—is becoming more apparent every day, not least yesterday, following the Autumn Statement. The OBR has reacted to the statement by giving us an independent assessment of where we are now and where we are likely to be, as a nation, as a result of the actions of this disastrous Government, who cannot even stand up for their own judges, let alone stand up to their own right wing.

The Government say that we have a £220 billion Brexit black hole and will have rising unemployment, lower wages and higher inflation, resulting in lower living standards. The projected fall of £8.2 billion in tax receipts over the next two years will seriously impact on our public services. That fall is enough to fund more than 330,000 nurses.

It was shocking that there was not a single mention of social care in yesterday’s Statement from the Chancellor, despite the £1.3 billion hole in social care budgets needed by 2020 simply to stabilise the system, let alone deal with rising demand and reverse the fall in the number of people able to squeeze through the rising eligibility barriers for care. More than two-thirds of acute hospital trusts are in serious deficit and this figure is projected to rise. These are the real effects of Brexit on our national treasure. We cannot pay for the staff we need in the NHS and social care if tax receipts are falling unless the Government make different choices.

Our public sector workers have not had a decent pay rise in years and are promised in the coming year less than expected inflation—in other words, a real-terms pay cut. That is why we on these Benches called for the Chancellor to announce £4 billion extra for the NHS and social care yesterday and a decent pay rise for public sector workers—but he did not. Instead, we will be spending much more than that on additional civil servants charged with getting us out of the EU. You could not make it up.

In addition to that situation, since 23 June there has been enormous uncertainty, as we have heard from other speakers, among providers of health services and social care about whether they will be able to retain the staff from EU countries already here and recruit new ones in the future. The current staff from these countries are valued and essential to the operation of health and social care, and yet the Government refuse to give them any reassurance. Thirty thousand doctors, 55,000 nurses and others, 90,000 care workers and goodness knows how many medical researchers from the EU are currently working in the UK. Without them, the NHS and care services would fall over and our research efforts will be damaged. EU funding supports many of our medical research programmes and I am very concerned that without it, after Brexit, UK patients will no longer benefit from clinical trials and early adoption of the cutting-edge treatments that they bring.

Others have picked up their own areas of concern about the health and social care workforce but I should like to mention two groups: midwives and people supplying medical equipment. In April this year there were 1,192 full-time-equivalent midwives from other EU countries working in the NHS in England, according to figures from NHS Digital. In London alone, 16% of the NHS midwifery workforce was from elsewhere in the EU—674 full-time equivalent midwives. At University College London Hospitals NHS Foundation Trust, 32% of the midwifery workforce was from the EU. Outside London, in both Basildon and Thurrock, and in Walsall, more than 10% of midwives were from other EU countries.

On the latest calculation, the NHS in England is already short of around 3,500 full-time midwives. Without EU midwives, that shortage figure would be over 4,500. We need more midwives, not fewer. The Royal College of Midwives believes that any policy that could see EU midwives blocked from continuing to be able to work in the NHS post-Brexit would be very damaging for maternity services across the country and truly catastrophic for London. Can the Minister tell us what plans the Government have in their negotiations to protect our maternity services?

The information I have just mentioned concerns the proportion of the current midwifery workforce coming from the EU. It does not take account of how many join or leave in any one year. It is important to consider this churn because, even if existing EU midwives were able to stay, any who then returned to their home country might not be easily replaceable. The latest figures available on that churn, from September 2014-15, show that during that period 189 EU midwives left NHS employment and 248 started—a welcome increase. Simply allowing existing EU midwives to stay without taking any account of allowing new ones to come would lead to a fall in numbers. In summary, the NHS in England has been short of midwives for years. We need all the midwives we can get; currently well over 1,000 of those we have are from other EU member states. We need them.

Turning to my other concern, many people working in health and social care are involved in the provision and support of medical devices for their patients. Brexit will pose problems for them, too. At present the UK is closely involved with EU regulatory bodies in licensing about 150,000 medical devices. Licensing by these EU bodies ensures that patients receive safe and appropriate medical equipment. It also means that the businesses responsible for their research, development and sale can trade easily within the EU, and with other countries, based on EU-wide approval. There are thousands of jobs in these businesses and they affect millions of patients.

Many EU countries value UK expertise in the regulatory field and much of the approving of medical devices for use across the EU is done here in the UK. Casting us adrift from this EU-wide process and creating a wholly separate regulatory process will weaken the process of approving innovative medical devices and create barriers for businesses working to develop them.

Who knows what the results of negotiations will be, but it would make sense to continue the regulation of medical devices on an EU basis. However, that will not be possible if the EEA, EFTA or customs union models are rejected. What we do know is that creating a “bespoke” regulatory process as part of a hard Brexit will make it more difficult to develop and get approval for the kind of medical devices that will assist those working in health and social care to support patients properly, and in many cases to help them live their lives as independently as possible. That includes patients of all ages with chronic conditions, elderly people, people with disabilities and people with learning difficulties.

Creating our own bureaucracy for regulating medical devices will be costly and at the expense of direct support for people who may benefit from them. Why spend the money on new bureaucracy rather than on more prostheses, heart pacemakers, computerised blood sugar regulators, mobility aids and much more? In addition, failing to maintain EU-wide systems will threaten their future development here in the UK. If we are to leave the EU, the UK businesses that are researching, developing and promoting medical devices would clearly prefer a new arrangement in which the system remains EU-wide, even if that means a loss of sovereignty and the need to pay a share of the costs of EU-wide regulation. If the Government are determined on a hard Brexit to appease their right wing, however, this important UK industry will suffer, work will move to the EU, and those working in the health and care sector will find that the changes have been detrimental to their patients. There could be huge and unnecessary costs for the supplying of medical devices if there are not, at the very least, long transitional arrangements allowing issues such as labelling to be addressed. Will the Government’s industrial strategy take account of this important health-related industry?

The process and consequences of Brexit will cost this country millions and have already cost us trillions of pounds because of the fall in the value of the pound. What will the Government do to minimise the negative effect of Brexit on the health of the nation?

My Lords, I also congratulate the noble Baroness, Lady Finlay, on securing the debate and giving us this opportunity in her usual clear and erudite manner. I refer noble Lords to my interests in the register.

It is pretty obvious that the noble Lord, Lord Hunt, could not be here today. I am sure he is almost as unhappy as I am that he is not here, but this has been rather a depressing debate. Of course, this is not the first time we have had a debate on this topic. When we had our earlier debate in July, the noble Lord, Lord Prior, suggested that we should have another debate in three or four months’ time, when he must have presumed that we would have more clarity on the Government’s thinking. I therefore very much look forward to hearing what he has to say today.

Two messages are clear from virtually every noble Lord who has spoken. First, the NHS and social care are in dire straits. Every report we see and everything we hear from people working in these services say the same thing. Even the National Audit Office and the Public Accounts Committee say that we cannot go on as we are. The Chancellor did nothing yesterday to offer any relief.

On top of that, we are threatened by the possibility of losing the support of our EU immigrant staff on whom we rely so heavily—a double whammy. Everyone who has spoken today, and everyone both inside government and outside it, say the same thing: that these staff represent an invaluable asset and provide vital support for the NHS and social care.

I sit on the Select Committee on the Long-Term Sustainability of the NHS. While the ostensible purpose of that committee is to gain an idea of what the future will bring for the NHS in 20 or 30 years, we have been unable to get any of the innumerable witnesses who have come before us to engage in anything but the immediate problems they face today. They are entirely taken up with how they are going to survive this next year and cannot lift their heads up from firefighting today.

I shall not reiterate the catalogue of uncomfortable data that we have heard today which emphasise the size of the problems we face, save to mention just a couple of the most glaring facts. My noble friend Lord Lipsey spoke so clearly about social care, where the 25% cuts that we have seen over the past few years are causing the most acute problems. According to Age UK, 1.8 million elderly people are not receiving the care they need—the noble Baroness, Lady Brinton, spoke of 1.2 million; I do not know which figure is right, but both are awfully large numbers.

Last week’s debate in the other place spelt out in unhappy detail the dire problems due to the cuts in local authority funding. Now the CQC and the Local Government Association talk of social care services being at “tipping point”. In the NHS, eight out of 10 hospitals say that they cannot ensure a safe rota of nurse care throughout the day and night. The Royal College of Paediatrics and Child Health tells us that it cannot fulfil its rota arrangements as its paediatric vacancy rates rise. Everyone, from the royal colleges, the King’s Fund, the Nuffield Trust and now even the GMC, is warning of the impact of the cumulative shortfall on standards of care—the noble Lord, Lord Warner, laid it all out in depressing detail.

This week, I met a young doctor working in a large London teaching hospital who told me that he had just spent a 10-hour stretch without a break in the A&E department. When I asked him how many of the patients whom he saw did not need to come to that department, he said that the great majority should have been dealt with by their GPs if only they did not have to wait a couple of weeks for an appointment. What a sad state of affairs. Now the public are waking up to the problems, as newspapers begin to show pictures of queues of patients lying waiting for hours on trolleys in A&E departments.

It is against that background that we have to face the possibility that 5% or 10% of the workforce might be lost if we do not take action to prevent the potential damage of Brexit. We have heard the figures: a vulnerable 5% overall and a particularly severe impact in London and the south-east, where 10% of the workforce are EU immigrants. The figures are frightening. In London, more than 40% of social care workers are immigrants. In nursing, already with 23,000 vacant posts, they are desperate to reassure and retain the 33,000 nurses trained outside the UK who now feel rather insecure. Midwifery is no better off. A striking example of its vulnerability is UCH, 32% of whose midwives are qualified in the EU outside the UK.

Among the 30,000 doctors on the UK medical register and who qualified in other EU countries there are many vulnerable specialties such as surgery, psychiatry and so on. There is a particular case in the large teaching hospitals that are so attractive to academic clinicians from abroad. Overall, 15% of academic clinicians in our hospitals qualified in the EU. They can go almost anywhere in the world to work. Will we be able to keep them here and will we continue to attract a continuing stream of them? We will certainly be at a disadvantage if we lose our capacity to attract them. The noble Lord, Lord Bilimoria, spelled out the need for scientific collaboration.

We have heard all sorts of encouraging words from the Secretary of State, the Prime Minister and the noble Lord the Minister about how much they value the contribution of our immigrant staff and how important it is to reassure them that their future is safe. However, there remains considerable uncertainty in the minds of many and this perception is not helped by the way that the Government keep their negotiating cards so close to their chest. There is a feeling among our own EU staff that they are being used as bargaining chips in the negotiation to strengthen the position of UK expats living in other EU countries—that if they can stay there then we can allow EU healthcare workers to stay in the UK. That may be a cynical view and it will probably be denied, but that is certainly one perception that is difficult to dispel.

Let me briefly outline a couple of other areas of concern. First, in public health, we rely on the European Centre for Disease Prevention and Control to work closely with our own Public Health England laboratories for the rapid detection of outbreaks of infectious diseases and the sharing of information about them. As the noble Baroness, Lady Finlay, said so powerfully, infections, unlike immigrants, know no borders, and we can ill afford a barrier to the flow of information. What discussions are being held to ensure that we can maintain this vitally important link?

I mentioned the need to attract academic clinicians, but what is the Government’s plan to deal with the fall-out when the European Medicines Agency moves out of the UK, as is now inevitable? We will certainly lose jobs, but currently we have very close and invaluable access to the EMA by industry and researchers engaged in clinical trials. This will be lost unless we can make special arrangements. What thoughts have the Government given to dealing with this problem?

The European working time directive has had its critics, but its aim to improve the health and safety of our staff should not be readily jettisoned. Will we be able to retain it or something similar?

Several other actions the Government could take might offer some mitigation. For a start, they could certainly be more open about their intentions for this particular group of workers. The suggestion that they do not want to reveal their negotiating hand too early really does not wash. Surely starting with a strongly stated and clear position on what we require can only strengthen our position.

What about the status of the Migration Advisory Committee? I understand that it maintains a shortage occupation list that provides for certain groups of staff to come to work in the UK from abroad, and that this includes nurses. Will the noble Lord consider the prospect of expanding that committee’s list of permitted staff to include a range of threatened and vitally important NHS staff?

To reiterate the plea from the noble Baroness, Lady Finlay, about the Medical Training Initiative that we currently operate for non-EU specialists to come to the UK for two years’ training before they return home, is there a prospect for that scheme to be expanded to incorporate EU doctors across all specialties?

As far as doctors and nurses already here are concerned, can the Minister confirm that if they are now on the register they will continue to be recognised and as a result will be able to continue to work here? That would go an enormous way to reassure them. There are many steps the Government might take to reassure both our services and our immigrant staff. I hope that the noble Lord, Lord Prior, will be able to offer some comfort.

My Lords, when the noble Lord, Lord Turnberg, said that this has been a depressing debate, he was not exaggerating. The noble Lord, Lord Warner, referred to “A Streetcar Named Desire”. Frankly, I feel more like Hamlet:

“To be, or not to be”.

It has been a very thought-provoking debate and I thank the noble Baroness, Lady Finlay, for raising this hugely important issue. If there has been some deviation from the subject on the Order Paper, that is perhaps understandable, given how important the issue is. In thanking the noble Baroness, I echo the remarks of the noble Lord, Lord Wigley, about the work she has done in palliative care in Wales. I know she has had a huge impact on healthcare in Wales. Indeed, that has extended to Norfolk because she has been to Norfolk a few times as well and I know that that is hugely appreciated.

Before I get into the meat of the subject, I will pick up the point about people who work in social care. The noble Baroness said that the turnover rate of people who work in social care is 37%, which is a pretty shocking figure. You cannot run a business if you have a staff turnover of one in three; you certainly cannot deliver good-quality care. I see my noble friend Lady Cavendish sitting in the corner. The Cavendish report that she produced four years ago, which introduced the care certificate for people working in social care, has had a huge impact. I think there was a worry at the time that it was another piece of bureaucracy but it has had a big impact. Of course, the move to the living wage will have a big impact as well. I agree with the right reverend Prelate the Bishop of Ely and others that social care workers are a hugely undervalued part of our workforce. They do extraordinary work and I record the strength of feeling we all have in this House for the work they do.

There are three big issues running through this debate. First, there should be no doubt that the healthcare system, social care and the NHS depend on people from all over the world—from Asia, Africa and the Caribbean as well as Europe. It will always be so and we are hugely in their debt. The Health Service Journal held its awards yesterday and Alastair McLellan, the editor, said:

“The NHS has always relied on people from around the world to help it deliver for its patients and even accounting for planned welcome increases in home grown staff, it always will”.

I echo those words and would add people who work in social care. We owe a huge debt to all those people. They play a vital role.

The second theme is this: like most people who contributed to this debate, I voted to stay in the EU and I have not changed my mind about that. I voted to stay in the EU and I would like to have stayed in the EU. As was mentioned by the noble Lord, Lord Lipsey, sometimes it is as if we in this House are preparing a dossier on why the British people got it wrong. It is about time that we listened to what the British people said. They voted to leave the European Union. It does us no credit as a House to keep on moaning about why we have left. We have left. Let us make most of it.

We have voted to leave the European Union. We now have to make the most of it. We can make the most of it and we can make a success of it. We can use Brexit as a catalyst for change. Even though most people, like me, wanted to stay in the EU, none of us felt that the EU was perfect. Most of us felt that it was a deeply flawed institution. Now that we will be outside the European Union there are huge opportunities that we can take.

The third theme is immigration. Immigration has been hugely beneficial for our country, not least for the NHS but for our country as a whole, and we should celebrate that. But that does not mean to say that uncontrolled, high levels of immigration cannot do damage to our country. The tone of the debate, both in the US around the election and here around Brexit, was often deeply shocking, deeply unhelpful and, as many others have mentioned, deeply deplored.

However, let us not pretend for one minute that all the difficulties around immigration in this country stem from those two debates. No one can say that the “Black Lives Matter” campaign in the US suddenly started when Donald Trump became President-elect. No one can say that the problems which people from BME backgrounds have with the criminal justice system, or have in the NHS, suddenly stemmed from Brexit. Many of these issues are much more profound, much deeper and much more fundamental than that. Controlled levels of immigration can undoubtedly enrich this country materially and culturally, but uncontrolled immigration runs the risk of damaging both those things. Those were the three big issues that ran through this debate.

I turn to the scale of the issue that confronts us. There are 57,000 colleagues from EU member states working in the NHS and about 90,000 working in the social care system. As we heard from my noble friend Lord Colwyn, there are 7,000 dentists from the EU. We know that the proportion of overseas and EU staff is much higher in some parts of the country, especially London. We also know that there is a huge impact on our life sciences industry—I took note in particular of the comments of the noble Lord, Lord Bilimoria, on this—from EU nationals and people from other parts of the world. The collaborative work we do across the EU in life sciences is extremely important. Cancer Research UK says that between 30% and 40% of all its research is done in collaboration with EU nationals. As we put together our strategy for the life sciences, as part of the industrial strategy, I assure the noble Lord that access to the world’s best talent will be absolutely centre-stage and critical.

There should be absolutely no doubt that the UK benefits from immigration, but reducing net migration is compatible with continuing to attract hard-working and skilled people who come here to study and to work. The immigration system will always have a role to play in supporting growth and meeting the needs of UK businesses. People from overseas fill vital gaps in our labour market in social care, nursing, medicine and science.

The Prime Minister has been absolutely clear that she wants to protect the status of EU nationals already living here—incidentally, this was also the view of her predecessor, David Cameron—and that the only circumstances in which it would not be possible is if British citizens’ rights in European member states were not protected in return. Some degree of reciprocity does not seem unreasonable. Personally, I regard the chances of that happening as being so remote as to be almost inconceivable. My right honourable colleague the Secretary of State for Exiting the EU, David Davis, also made this clear when he said:

“We will always welcome those with the skills, the drive and the expertise to make our nation better still. If we are to win in the global marketplace, we must win the global battle for talent. Britain has always been one of the most tolerant and welcoming places on the face of the earth. It must and it will remain so”.

Can the Minister explain this one fact? We have had uncontrolled immigration from the European Union, and we have heard from all quarters in this debate that the NHS and the care sector are highly dependent on those people. We have more than 3 million people from the EU living and working here, yet we have the lowest level of unemployment and the highest level of employment in living memory. How would we have managed without these people? If people voted to leave because of the burden of immigrants on the public sector, we have just proved in this debate that without those immigrants they would not have the public sector.

I repeat what I said earlier: the contribution made by people coming into this country from the EU and elsewhere has been enormous. It was clear in the Statement yesterday that one of the great fundamental problems we face in this country is low levels of productivity. If we are to afford the kind of social care system and health system that we want, we have got to increase levels of productivity. It has been too easy for us in this country to rely upon people coming from overseas rather than training our own people.

I strongly believe that that is why we must focus on areas such as life sciences, for example, where we have huge strength in research and high levels of productivity. That is the only way that we are going to be able to afford to have the kind of health and social care system that we need. I agree with David Davis. The Conservative Party is unashamedly internationalist, outward-looking and global in its outlook. There is no place for jingoistic, xenophobic or little England views in our party. On the contrary, we look out to the world, a world that includes Europe, but is not defined by Europe. Noble Lords deplored the xenophobia that appears to have increased since Brexit, and I entirely share their views. There can never be any excuse for that kind of attitude.

We recognise that we cannot continue to rely on people from overseas to maintain the level of staff that is required within our health and care system, nor is it right to do so. If we are honest with ourselves, we knew this before Brexit. We must become more self-sufficient. Indeed, this is consistent with our commitment to the World Health Organization’s priorities on human resources for health. It cannot be morally right for a rich country such as the UK to recruit skilled doctors, nurses and other workers from countries whose need is so much greater than ours, so we will take a range of actions to increase the supply of domestically trained staff and to increase efficiency through better use of technology and skill-mix solutions.

In respect of the NHS, we have already increased the number of key professional groups being trained. For example, since 2013 the number of nurse training commissions has increased year on year by some 15%, and we expect to have 40,000 more nurses by 2020 than we had in 2015. We are committed to ensuring that there will be 5,000 more doctors working in general practice by 2020. From September 2018, the Government will fund up to 1,500 additional undergraduate student places through medical schools in England each year. This is in addition to the 6,000 medical school places currently available in England. That is a very significant increase. It is 1,500 places each year on a five-year course, so that is an extra 7,500 doctors coming through the system. The recent reforms to the funding of training for nurses and allied health professionals will further increase supply by removing restrictions on the number of training places, so that universities are enabled to deliver up to 10,000 additional nursing, midwifery and allied health training places over the course of this Parliament.

Nevertheless, it is important to recognise that it takes time to train skilled health and care professionals, and therefore we have introduced initiatives to improve retention and to encourage trained staff to return to practice. We are also working to increase the efficiency with which we use our existing staff and to improve productivity by changing the skill mix through the introduction of new roles, such as physician associates and nursing associates. This will ensure that highly trained professional staff are properly supported and more productive. We will also see over the next five years a huge increase in the use of digital technology to enable more people to be looked after outside hospital settings.

We all recognise that social care is a vital service for many older and disabled people. The Department of Health is working with Skills for Care, employers and Health Education England to support activity to recruit and, importantly, retain our caring and skilled workers who work in social care. In many ways, these people are the unsung heroes of the health and social care system, delivering very personal care to very vulnerable people at very low salary levels. Since 2010, we have seen more than 340,000 new apprentices into the workplace in the care sector, which is more than any other sector. So we are taking action to increase our home-trained workforce in medicine, nursing and social care.

I do not want anyone in this House to think for one minute that we underestimate the challenges that Brexit presents to the health and social care system, but I think it also presents huge opportunities. It behoves us in this House just occasionally to look on the slightly more optimistic side, and not to be quite as depressing as we sometimes are.

Before the Minister sits down, could he address the issue of reciprocity, which some of us raised? There is no incentive for the EU to give guarantees on reciprocity, so why should it move on this area at this point? We stand to lose because those people will actually leave unless they are given guarantees. If we are going to wait to reassure these people until there is reciprocity, we are bound to lose that argument. Why can we not move on this issue before reciprocity?

My Lords, we have not even triggered Article 50 at this point. It would be pretty strange for us to start taking unilateral action until at least the article had been triggered and negotiations had begun.

My Lords, I thank everyone who has spoken in this debate. I wish I could go through each contribution individually but time will not allow that.

I am very sorry that the Minister thought the debate was a moan, because it really was not. I do not think anyone here has moaned; rather, everyone has laid out facts and figures to try to demonstrate the problem that we have to tackle. The Minister spoke of huge opportunities, and it is to be regretted that no one who campaigned to leave was here to spell out what those opportunities might be, which they could have done. I offered up a couple and asked a question about them, but got no response. I look forward to the Minister perhaps writing to me in future and answering them—simply about the GMC’s powers and so on.

The debate has demonstrated that there is indeed a gaping gap. We risk haemorrhaging staff. A perfect storm is brewing, as has been spelled out today. Yes, we need to train our own staff, but this is not just about training places; this has to go right back into schools and across society to change attitudes, as has been said, so that care is viewed as esteemed work to go into. Our research cannot happen unless the regulations and routes for collaboration are in place and wide open and people feel welcome. I am sad that we have had no assurance on that today.

The phrase “addicted to overseas staff” is absolutely correct. Perhaps this debate has demonstrated that cold turkey is going on, as we realise that they are not going to be there in future and we cannot carry on with that addiction. The heart of our country is indeed at threat. The prejudice that people have experienced has been ugly. We are at a tipping point if we are going to lose that 5% to 10% of qualified European staff, who are certainly feeling uncomfortable and getting cold feet about remaining.

To close, I simply wish to say that I do not believe this was a negative debate. People were trying to be very constructive and lay out the problems. Unless you know the problem, you cannot find a solution. We cannot simply come out with bald statements along the lines of, “Don’t worry, it’ll be okay in the longer term”.

I thank most sincerely everyone who contributed. I beg to move.

Motion agreed.