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NHS: Staff

Volume 787: debated on Thursday 30 November 2017

Motion to Take Note

Moved by

To move that this House takes note of the impact of Her Majesty’s Government’s fiscal policies on the recruitment, retention and conditions of NHS staff.

My Lords, I am looking forward to this debate. I think it will be an excellent debate, with a wide array of speakers representing a great deal of experience right across the health and care service.

We all know that the NHS is one of the living institutions of our country, loved, appreciated and needed by its people. In spite of the difficulties facing it, the service it provides is second to none as the British people seek medical attention and healthcare. Year after year, surveys show that it is regarded internationally as the most efficient organisation anywhere in delivering healthcare.

I shall be a little provocative in what I am saying at this moment. I know it causes some discomfort to some Members on the Benches opposite that a state institution employing 1.3 million people can compete successfully against private medicine. When I say that, I do not include the Minister because I know he is committed to the health service, but I believe there are people in the Conservative Party who find the NHS uncomfortable. It was interesting that the Secretary of State chanced his luck when he alleged recently that the NHS was actually invented by the Conservative Party—a case utterly rebutted by my noble friend Lord Pendry on 2 November in a letter to the Guardian, so I do not need to take that further.

I trust that when we on this side speak today, the Minister will understand the strength of opinion that the Government are slowly but surely allowing the NHS to deteriorate. Several years ago, when I began to question Health Ministers on the NHS, the situation was precarious. Now it is getting almost desperate. The bottom line is that the Government are not providing sufficient funds to meet the demands of an increasing and ageing—we must take those two facts together—population, and that no clever words can hide the fact that they are breaking their manifesto policy to increase spending on the NHS in real terms year on year. If you look at the anticipated spending, you can see that that will not be the case.

I mentioned 1.3 million employees. Those employees are proud to work not for the health service but in it. The service is at its most efficient only when it works as a team. Everyone is interdependent. I feel at times that the Government do not really appreciate that fact. If there is one thing lacking in our NHS, it is that it has no central workforce planning, and that is of real concern.

At the moment, almost all employees feel the same—demoralised and undervalued. They give their all, and more and more people are treated. But the staff feel that their treatment by the Government shows that they are not regarded highly enough. They feel that they are the individuals who suffer most from the Government’s now out-of-date austerity programme. Wherever we look—whether at consultants, doctors, nurses, midwives, healthcare assistants, physiotherapists, radiotherapists, GPs, clerical staff, porters, ambulance drivers, dentists or the scores of other occupations in the health service—it is the same story. The Minister must know this because I know he talks to staff. They feel demoralised and undervalued. Yet, these are the very people who keep our NHS going. It is because of them that patients still get a good service. However, it is slowly getting worse again. We are finding, in spite of the best efforts of staff that waiting lists are growing month by month. Increasingly, deadlines for cancer treatment are being broken. In spite of the Government’s bold declarations, the future for mental health services does not look as good as it should.

Following the Budget, I noticed that initially the press lauded the Chancellor for what he appeared to be giving the NHS. However, after examination of the small print, the general public, the press and those involved increasingly realise how short-changed they were by the Chancellor. They took on board Jeremy Corbyn’s comment that the money, was “well short” of what is needed. Sir Bruce Keogh tweeted that the Budget,

“plugs some, but def not all, of NHS funding gap … Worrying that longer waits seem likely/unavoidable”.

Sir Malcolm Grant, chair of NHS England, said that the money,

“will go some way towards filling the widely accepted funding gap … we can no longer avoid the difficult debate about what it is possible to deliver for patients with the money available”.

NHS Providers stated that,

“tough choices will be needed and trade-offs will have to be made … It is difficult to see how the NHS can deliver everything in”,

the forthcoming year. I understand that just today the NHS England board is discussing what will happen—whether we will have rationing in health. This is against the background of the speech by Simon Stevens, chief executive of NHS England, who on 8 November said that an extra £4 billion was needed in 2018-19.

Yet only the Government seem to deny there is a problem. To pluck a number of key employees, we are short of 40,000 nurses. Recruitment from the European Union has all but dried up. Wages have been frozen at 1% since 2010, leading to a reduction in salary of 10.1% for nurses by this year. Unsurprisingly 70% of nurses reported feeling financially worse off, with 24% saying there were thinking of leaving their job because of money worries. The Government claim that there are 13,300 more nurses than in 2010 and 11,800 more doctors in hospitals. However, we have to question those figures. I do not dispute that they apply in hospitals but when looking at healthcare, we are talking not only about primary care in hospitals but aftercare—the care service. I have letters from care providers saying that they have had to close down some of their institutions because they simply cannot recruit nurses. There are insufficient nurses in this country.

It is no better for doctors. The BMA found a 13% decrease in applications to medical schools since 2013. Last year, there were 7,660 medical students beginning their course, compared with nearly 8,000 in 2010. GP numbers are falling. Almost one-third of GP partners are unable to fill vacancies. Only 13% of partners report that they do not need to fill vacancies, and figures show an actual decrease in the number of doctors working mainly as GPs. The result is that patients are having to wait longer and longer to get an appointment, increasing the demand on A&E departments in our hospitals, which are already under great stress. There needs to be some joined-up thinking.

Even if we go to the top of the tree and look at consultants, we find what I can only describe as a dire situation. The NHS has a shortage of consultants and would-be consultants. During the past year, 1,542 consultant posts were advertised, but only 853 certificates of completion of training issued. Not surprisingly, 45% of the advertised posts were left unfilled. There simply were not the qualified candidates. Ninety-five per cent of doctors in training report that poor morale is having a negative impact on patient safety in their hospital, with half reporting a serious or extremely serious impact.

I do not really need to continue. Perhaps I could sum up this point by citing the president of the Royal College of Physicians, Professor Jane Dacre, who neatly summed it up in her response to the Budget. She said that it,

“felt like we had been given short-term sticking plasters rather than the long-term sustainable plan our patients need”.

It is all very depressing. The Government take the view that it is really not their fault, but a lot of it is. I have to ask: why, when they came to office in 2010—with their coalition partners, but they were by far the leading partner—did they cut nurse training numbers by 22,000? It takes a long time to build up the shortfall that has been allowed. Why, at this critical moment when we do not know whether we have enough nurses or doctors—the Government say we have; I say we have not—why risk the numbers by abolishing the bursary scheme? It is a risk, and the Government know that there are fewer nurses going into training this year than in previous years. I do not have the precise figures but all the universities that I have contacted, with one exception, have found a considerable decrease. If there is no problem with nurses, why was it announced yesterday that we are to step up our recruitment of 5,500 more nurses from India?

I am being a bit critical of the Minister. I hope he will not take it personally but take this opportunity to write to me to correct the information. Last week, in a straightforward Question about agencies, I asked,

“what are the names and locations of the agencies registered to supply nurses to NHS trusts in England”?

It was a straightforward Question, but the Minister’s reply can be described only as gobbledegook. He said:

“Agency rules require that agencies are on NHS Improvement-approved frameworks and these frameworks monitor and approve agencies for supply to trusts. The approved framework operators are Crown Commercial Service, NHS Collaborative Procurement Partnership and HealthTrust Europe”—

I think HealthTrust Europe is an American company. The Answer continues:

“In addition to agencies on approved frameworks, trusts in exceptional patient safety situations can utilise the ‘break glass clause’ and work with an off-framework agency. Using an off-framework agency should be a culmination of a robust escalation process sanctioned by the trust board. Trust boards have primary responsibility for monitoring the local impact of the agency rules and ensuring patient safety”.

I spent a lot of time trying to understand it, and I have understood a bit of it. I have also found out—the latest figure I could get for any particular week—that there are 50,000 applications to use the “break glass clause”. Are those 50,000 nurses from agencies included in the Government’s figures?

My Lords, may I quickly say that there has been a mistake over the timing? If everybody speaks for 13 minutes, we will go two minutes over time. If possible, will your Lordships stick to 12 minutes? When the clock says 12 minutes, will noble Lords please sit down?

My Lords, I thank the noble Lord, Lord Clark of Windermere, for bringing forward the debate today. It is high time that we debated the fiscal issues in relation to health.

Although it is always nice to see the noble Lord, Lord O’Shaughnessy, answering a debate, I fear he is the wrong Minister for this one. Indeed, I think there should be a whole row of Ministers sitting on the Government Front Bench today, led by a Minister from the Treasury. Here is the reason. Noble Lords who know me will recall that my favourite word in health debates is “prevention”. Without prevention of a great deal of the country’s ill health, of which we are perfectly capable, the cost burden of preventable diseases will bring the NHS to its knees. Our hard-pressed health and care workers will never be able to work hard enough. My party’s policy, for the moment, is to add one penny in the pound on income tax for health and social care, while continuing to take lower-paid people out of tax altogether by raising the personal allowance. However, while this would provide the NHS and social care with what they need for the moment, in the long term, this will not be enough if we carry on the way we are going.

I am a great believer in evidence-based policy and also a great admirer of Professor Sir Michael Marmot and his rigorous work on health inequalities and the social determinants of health. That is why I said what I did about the Minister being the wrong person to answer this debate. If you want to lead a healthy life, all the evidence shows that you need to be conceived and born to a family that is comfortably off. The Marmot indicators show very clearly that poverty and deprivation are the clearest indicators pointing to poor health. So what are the factors that contribute to this—those things known as the social determinants of health? Of course, they are low income; poor housing; low educational attainment, leading to lack of well-paid work; poor air quality; poor access to the cultural activities that contribute to our well-being and mental health; and poor access to the healthy food, help and advice that help us make the right choices for our own health.

So until we get a truly progressive tax system that taxes poor people less than rich people, until we stop subsidising the fossil fuels that pollute our air and warm our planet, until we train a highly skilled workforce and until we start building affordable well-insulated homes for poor people, we will never iron out the major health problems that keep our doctors and nurses far too busy. That is why we should have a Treasury Minister leading a team of Ministers from transport, housing, education, DWP, DCMS, DCLG, BEIS, Defra and all the other acronyms. Until we get a whole-government approach to the health of the nation, we will never solve the problems of health and social care. So as the noble Lord, Lord Clark, has rightly identified, fiscal policy is a powerful tool in this battle. I would like to hear the Minister say that the Prime Minister will show a bit of leadership on this and set up a powerful Cabinet sub-committee with teeth, which will be able to hold all the other departments to account on their contribution to the health of the nation. Until I hear about some mechanism of that sort, I fear that the Marmot indicators will never shift.

In addition to that, we politicians need to put our heads together. I fear that the Government’s failure to heed the calls of my right honourable friend Norman Lamb MP and others to put together a cross-party commission on a sustainable health and care service is very wrongheaded. Good-quality health and social care are things that people care about and vote about, and they depend very much on the welfare of staff. So I would have thought that any sensible Government would prefer to bring in all points of view to find the answers to a problem that has been growing for years, as the noble Lord, Lord Clark, just said. And no, the Government do not have all the answers. This House’s Select Committee, led by the noble Lord, Lord Patel, had many of the answers, but they nearly all involved money, yet what did we get in the recent Budget for an NHS that needed more than £4 billion extra and a care system that needed £2.6 billion? We got £1.6 billion for the NHS and nothing at all for social care. But of course, we got £3 billion put aside for Brexit. How many doctors and nurses could we get for that?

It is clear that the overwork, stress and effective pay cuts suffered by our doctors, nurses and other health professionals will continue. These are contributing to their low morale and the fact that many of them want to leave, cut their hours or retire early. The public service pay cap imposed by the Chancellor for many years has not been lifted, despite a comment to the contrary by Jeremy Hunt. The small easing of the pay restraint announced by the Chancellor last week is conditional on the money being saved elsewhere by the removal of year-on-year increments of other health workers. It is all about saving money, not patient safety, yet patient safety is a big issue when you have demoralised staff working longer than they should in a team with vacancies. The Royal College of Physicians told us that 69% of doctors work on a rota with vacancies and that 74% of them are worried about the ability of their service to deliver safe care. Half of those polled by the RCP believe that patient safety has deteriorated over the past 12 months. What are the Government doing to ensure patient care?

What about nurses? The Royal College of Nursing has reminded us that, since 2011, nurses’ pay has dropped in real terms because their tiny pay awards have nowhere near kept up with inflation. No wonder trusts are having difficulty recruiting and retaining enough nurses and we now have 40,000 vacancies. So trusts are having to turn to expensive agency nurses—and things will get worse if Brexit ever happens. Indeed, it is happening already as some nurses from other EU countries go home and the number of applications to come here has fallen by 96% in the last year. UK applicants, too, are being deterred from training by the withdrawal of the student nurse bursaries.

Another fiscal measure that is demoralising nurses is the serial cuts to the budget for continuing professional development. This has gone from £205 million to £104 million, and now £83.49 million, over two years, so the opportunities for nurses to increase their income by undertaking specialist training are diminishing. Will the Government restore that funding for CPD and also look again at the bursaries for student nurses?

We are very dependent on doctors from abroad, including from the EU countries. We are not training enough of our own doctors. Despite the increase in medical training places by up to 1,500 per year by 2020, this simply will not do while we have rising demand and some doctors going back to their home country. It takes 13 years to train a consultant, so what are we to do in the meantime? Further funding for specialist training for home-grown doctors will be required, as well as an assurance to those who come to us from abroad that they are welcome here.

I have a particular concern about the cancer workforce. I have been involved in an inquiry by the All-Party Group on Cancer about where we are at this point, half way through the timeframe of the cancer strategy in England. Are we on track to deliver all the objectives or not? Although the report will not be published until next week, I think I can whet your Lordships appetites by revealing that all the evidence points to the fact that we are not. In particular, my colleagues and I were very concerned about the evidence of workforce shortages. We are still expecting the strategic review of the cancer workforce from Health Education England, which was promised a year ago. We were told it would come in December 2017, which starts tomorrow. I look forward to it. However, its delay has meant that the shortages which are apparent all across the NHS workforce are even more severe in cancer services because of the specialist staff needed to achieve the strategy. We heard that the lack of the staffing review, delays in releasing funding from NHS England and the last-minute changes in the criteria for transformation funding have meant that cancer alliances have not been able to plan properly and have certainly not been able to commit to funding staff posts until they are sure that they have the money available.

The cancer workforce is just one sector where, because of the clear objectives in the cancer strategy, it has been possible to measure progress against aspiration. However, we heard from several sources that workforce is the greatest challenge to delivering the strategy. I believe that fiscal measures could improve the situation here and right across the NHS, if only the Government were willing to put them into place.

My Lords, the Motion before the House, so ably moved by my noble friend Lord Clark of Windermere, is indeed timely. As the House knows, the National Health Service is probably going through its most difficult time since its inception, yet the Government’s attitude seems to be one of utter complacency.

When the Government—or, more specifically, Jeremy Hunt, the Secretary of State—hint that staffing in the health service is a priority and they are investing in what they call the “front line”, it hardly squares with the facts. At a time when more people than ever are using its services, it seems obvious to almost everyone except the Government that the fall in the numbers of nurses and health staff will result in a shortage of these essential workers, which is estimated to be in the region of 42,000 in the near future. Problems are especially acute in spheres of nursing such as district nursing practice and nursing in psychiatric care, where there has been a reduction of some 12% since 2010.

That these shortages cause pressure is borne out. For example, two-thirds of the respondents to UNISON’s annual survey reported that wards were so understaffed that nurses did not feel that they could guarantee safe, dignified and compassionate care. One must consider that those were among the main reasons why most nurses wanted to work in the National Health Service in the first place—it was certainly not for the pay they would receive. It is a fact that, on top of receiving inadequate salaries—we know that is the case—many in the health service find that the pressure can often produce physical dangers for both patients and staff. UNISON’s survey of mental health workers revealed an increasing risk of attacks on staff, driven in part by shortages.

We are now witnessing a vicious circle in which shortages of staff lead to them having to take on extra workloads. That leads in turn to fears for their own safety and that of their patients, which is having a damaging impact on their morale, and hence staff leave the service in great numbers. Therefore, pay by itself is not the reason for the staff shortages; low morale remains an enormous barrier to recruitment and retention, and it must be addressed by the Government.

The fiscal policies of this Government remain a major factor, about which my noble friend has already spoken. The recent attempt in the Budget to loosen the purse strings was but a half-hearted measure. Despite all the warm words from the Tory party before and during the general election, nothing of real substance has emerged since. In truth, most National Health Service workers have failed to receive a pay rise worth speaking of since 2010, due to the pay freeze and the pay cap of 1%. It is no wonder that the Royal College of Nursing has reported a “growing number” of nursing staff using food banks, taking on additional jobs and accruing personal debt.

Jeremy Hunt’s latest revelation in the Health Service Journal showed that staff could potentially lose extra amounts for working anti-social hours under his so-called “more professional” pay structure. That prompted the Royal College of Midwives to accuse him of being “ill-briefed”, and Sara Gorton, head of health at UNISON, went so far as to say that talks between the Government and her union would be,

“a very short set of talks indeed”.

It is not right that both Scotland and Wales can give their health workers a living wage, yet their counterparts in England cannot.

Of course, all the problems aired in today’s debate have been compounded by the uncertainty and possibly larger problems which could be awaiting the National Health Service with our possible exit from the EU. For instance, there was the revelation in January 2017 that there had been a drop of 92% in the number of EU nurses registering with the Nursing and Midwifery Council. Surely that alone should have been a wake-up call for the Government to recognise the serious consequences for recruitment that could lie ahead. The number of nurses from the EU leaving the NHS increased by 38% last year compared with the previous 12 months, and a mere 46 nurses registered with the Nursing and Midwifery Council in April this year.

It is a fact that in some areas the National Health Service is dependent on workers from the EU, especially in London and the south-east. It is obvious—is it not?—that reassurances should be given. It is not enough for the Government to say that they are confident that EU workers in the NHS will be able to stay, with the rights that they currently enjoy; instead, they should give a concrete assurance that those staff will definitely be able to continue to work in the NHS post Brexit. After all, did not that same reassurance come from the mouth of Jeremy Hunt in his speech at the Tory party conference?

At the risk of being accused of repetition—I know that the Minister believes that I bring party politics into this—the reason one cannot take the Secretary of State’s word as gospel is that, in the same speech, he made a colossal blunder by stating that the NHS was the child of the Tory party and a certain Minister in the coalition Government, a Mr Willink, who introduced what he called a consultative document in 1944. This was issued before Nye Bevan introduced a comprehensive National Health Service, which was approved by 187 votes in 1947. Tory luminaries such as Sir Winston Churchill, Sir Anthony Eden, Harold Macmillan, Rab Butler and other notable Tories were against it, including the man whom Mr Hunt named as the founder of the National Health Service, the hapless Mr Willink.

With those words, I merely ask whether the Secretary of State can expect nurses, the nursing world and the National Health Service to believe his words and his authority when he tells EU workers that they are safe in his hands and his assurances about their rights to stay after Brexit. I doubt it.

My Lords, I thank the noble Lord, Lord Clark, for his introduction. I declare my interests as listed in the register: I am a retired nurse and a retired midwife. I joined the health service in 1953 as a student nurse and I have had a privileged career.

I find it very sad to stand here and talk about the health service we see today. I have read the evidence given to the Health Committee in the Commons and all the up-to-date figures, and I find it extremely worrying and sad that, from a nursing point of view, we are faced with an unsafe situation. We spent four years on the Health and Social Care Bill and emerged with the phrases that the Government would look at safe staffing and the certification of untrained staff.

Fortunately, we have the services of the noble Lord, Lord Willis, who has taken up the cudgel for people who were untrained nurses, and a two-year programme for support workers, agreed by the Government, has been introduced. The question is whether, as nursing associates, they will be registered. The problem is that the NMC is the registering body for the four countries, and not all four countries are doing the same thing with untrained staff. We are in a situation where we have uncertainty.

The noble Baroness, Lady Walmsley, raised the question of a multi-professional, multi-Government approach. The health service has reached a crisis point where it needs a global or overseeing way forward. I am particularly interested because during the past year I have had personal experience of health and social care, both as a Member of this House and as a regional nurse. I have had experience of transferring patients from health into social care. We have enormous problems which need to be sorted through a multi-professional, properly funded and reassuring to the public strategy.

We cannot go on having statements. To step forward we need to deliver safe care through the patient pathway, from before life to the end of life. We may need to use volunteers in some aspects—which is very good if they are trained—but the public still expect a service they can trust.

At the moment, there is a situation where people are wondering whether they will get safe care, when they are discharged in the middle of the night to a home where there is no one. We need to see that there is a pathway for them right the way through. I ask the Minister that we take seriously all the information that has come in about shortage of staff—not just nurses but all across the NHS. There is a need to work together and break down barriers that are there. We need more multi-professional education where it would be cost effective. We have not built in cost-effective ways going forward in some instances. Anatomy is anatomy, so why do we do not have anatomy teaching where we have all disciplines coming together? There are all sorts of innovative points we could do.

So, as a disappointed, retired nurse—and retiring Peer in the near future—I ask the Minister that the health service is revived so that patients and the public can have confidence going to a surgery or whatever their need, so that they can be assured that their health will be cared for. I rest my case.

My Lords, what a great privilege it is to follow the noble Baroness, Lady Emerton, and what a champion she has been for nurses, midwives and the health service. I think that the House will have another opportunity to pay tribute to her work but I am so pleased that she was able to participate in this debate.

I also thank my noble friend Lord Clark of Windermere for initiating this important debate. It is important because it is about the future welfare of about 1.3 million people in the NHS—let alone the people in their care—and they are all on the Agenda for Change pay system. But this is part of a wider context, which is important to remind ourselves of. The health service needs a higher ratio of spending as a percentage of GDP if we are to match the standards of other advanced nations, notwithstanding the extra resources required to care for our ageing population. The total UK health spending—including public and private expenditure—was 9.8% of national income in 2015 according to the Institute for Fiscal Studies. Although that was in line with the EU-15 average, it was below the levels of the United States at 16.9%, Japan at 11.2%, Germany at 11.1%, and France at 11%. Health spending has increased since 2009-10 but at an historically slow rate—1.4% a year. Also, it should be remembered that cuts in other departments, particularly local government, were disproportionately severe and have acted as a major obstacle to progress on social care. We must bear in mind that the average increase over the previous 60 years was 4.1% per year.

The second, larger bit of the context is that all the government reassurances about supporting the values of the NHS should be taken together with the appalling Health and Social Care Act. This was a top-down piece of legislation which created even more bureaucracy in the health service. It has not dealt with social care at all and many of today’s problems can be laid at its door.

In the 1960s I spent a couple of summers working as a ward orderly at Warwick Hospital, so I have been a health service worker—admittedly in a very different era and on a pretty low wage. I would march up and down the ward in a full-length cow gown—I am sure the noble Baroness, Lady Emerton, will remember the cow gowns—pulling a trolley full of urine bottles. I thought I was the bee’s knees.

For many years I was also a non-executive director at King’s College Hospital foundation trust. I chaired a considerable number of consultant appointment panels and was impressed by the calibre of the applicants, and the amount of training, study and moving around the country at frequent intervals that our system seems to require. I was also impressed by their internationalism. From whatever country they came, they had worked and conducted research in a different country from their birthplace. We are extremely fortunate to have people who are pathfinding in different forms of medicine and different methods of healthcare. The shortages in emergency medicine, psychiatry and general practice are extremely worrying and mean that some of our population may receive suboptimal care. What practical steps are the Government taking to address these shortages and maintain the internationalism of our consultants?

I will mention nursing briefly, not because nurses are not vital and recruitment and retention are not reaching crisis point, but because many other speakers, not least the noble Baroness, Lady Emerton, have far more expertise than I do. My former union, UNISON, is asking the Government to legislate for safe staffing levels so that acceptable nurse-to-patient ratios improve recruitment and encourage nurses to stay in the profession. UNISON’s annual survey in April this year showed that wards are now so understaffed that nurses cannot ensure safe, dignified and compassionate care. Half of respondents had to work through their breaks to make up for the lack of colleagues and 41% worked more than their contracted hours. This is leading to exhaustion and burnout.

UNISON has no confidence that the Government can deliver on their commitment to triple the number of nursing associates and increase the number of training places for student nurses. The demise of the bursary means the Government no longer commission training places directly, depending instead on universities creating extra places and recruiting students. One pro-vice-chancellor I spoke to two days ago said that his university was negotiating to establish a course of nurse training. It was so complex and demanding that the university doubted it would be financially viable or that it would actually run. Abolishing the nursing bursaries is in the same category as charging for employment tribunals and the notorious employee share ownership scheme—they should be put in the “daft” box.

I turn to the majority of health service staff—the unsung heroes and heroines, many in comparatively low-paid jobs who the pay cap has been particularly tough on: cleaners, porters, catering staff, admin staff, medical secretaries and primary care staff. This also includes professions allied to medicine: midwives, health visitors, healthcare assistants, paramedics, ambulance staff, occupational therapists, speech therapists and operating department practitioners. I make no apology for repeating my noble friend Lord Clark’s list of important staff. Since I mention speech therapists, I recall a debate many years ago initiated by my noble friend Lady Turner of Camden, who has a long-term illness. She was a champion of speech therapists. It was a very moving debate. The supporting speech by the noble Earl, Lord Attlee, was particularly powerful. We need more champions of health service staff, even with half the dedication of my noble friend Lady Turner and the noble Baroness, Lady Emerton. Such champions could make a difference.

I am sure that I have left some categories out and I apologise if I have. They have all paid the price of the Government’s austerity measures, in terms of living standards for their families and coping with increasing pressures in their workplace. While on the face of it the Chancellor’s announcement that the Government will give conditional support to pay review bodies this year is welcome, we do not know how many pay review bodies he is referring to. Can the Minister enlighten us as to who will be covered? Can he explain what the Chancellor meant when he spoke about,

“pay structure modernisation for ‘Agenda for Change’ staff, to improve recruitment and retention”?—[Official Report, Commons, 22/11/17; col. 1054.]

I have a lot of experience of pay structure modernisation. It usually means leaving people stuck on their grade ceiling, plussages which are divisive and discriminatory, and moving on to new pay structures on condition that staff accept unwelcome changes to their terms and conditions.

The Chancellor has said that any deal will be linked to improved productivity. Can the Minister explain what is meant by “improved productivity” in the health service? Would it involve a porter pushing two patients along in wheelchairs, catering staff serving half a dinner, or nurses scooting up and down wards? It would conjure an image of “Carry on Nurse” if it were not so serious. How on earth can people be expected to work any harder?

One of the complaints of staff, particularly nursing staff, is that there is insufficient flexibility in working patterns. I am not surprised that the bill for agency staff has nearly doubled between 2011 and 2016, reaching £3.6 billion in England and £250 million in the other nations. If I were a trained nurse with young children, I would probably opt for the flexibility of agency working, rather than the increasingly heavy burdens of full-time staff responsibilities. The House of Lords Long-term Sustainability of the NHS Committee looked at the link between pay and morale. Those at the lower end of the pay scale were particularly badly affected. The committee made this recommendation about pay policy:

“We recommend that the Government commissions a formal independent review … with a particular regard to its impact on the morale and retention of health and care staff”.

The Government have not yet responded to this recommendation. Will the Minister say what the Government’s response is to the committee’s recommendation?

Finally, paying lip service to the NHS and issuing overblown statements about how the Government support it, while at the same time squeezing it by the neck, is unacceptable. Actions speak louder than honeyed words.

My Lords, the noble Lord, Lord Clark, deserves our thanks for providing this opportunity to discuss what I would call the bleak direction of travel that this Government are setting for our health and care system. I congratulate him on his robust and thoughtful analysis, which I share. It was also a privilege to hear my noble friend Lady Emerton. I, like others, will miss her wisdom in the future.

Next year the NHS will be 70. For much of its existence it has had an annual funding increase averaging about 3% to 4% in real terms. Since 2010 the annual increase has shrunk to less than 1.5%. During this decade the NHS has become rather like a pensioner finding it difficult to live in the style to which it was accustomed. It now faces an uncomfortable old age, partly because it failed to change its business model when it had the chance, but increasingly because of this Government’s obsession with both a reckless Brexit and a linked fiscal policy based on unrealistic national debt reduction.

First, I acknowledge that the NHS has contributed, to some extent, to its current problems. For too long it has been reluctant to change its hospital-centric business model when the changing demography and disease profile of its customers strongly suggested that it should. For too much of its history too many NHS leaders have distrusted local government and, for the most part, until recently, have failed to understand the NHS’s dependence on a reliably-funded adult social care sector. Even when there have been sensible plans for change, an adequate investment strategy has usually been lacking. Certainly, there has been a failure to provide a strategy for reshaping a workforce that needed to work differently and more innovatively, embracing new technology in all aspects of its work. If you add in an expensive and misguided Conservative-led reorganisation five years ago, it is not difficult to see how poorly placed the NHS and its staff are to deal with what comes next.

The state of our health and care system is evidenced in the report by this House’s Select Committee on the Long-Term Sustainability of the NHS, of which I was a member. The report was published in April and we still await any response from the Government, other than the Minister telling us that it is on his desk. The report also presents a powerful body of evidence on the damage done to the prospects of NHS sustainability by the persistent failure by Governments to fund adequately adult social care, even taking account of the £2 billion now being invested over three years. This sector is experiencing a serious reduction in the provision and quality of publicly funded adult social care, as the loss of 4,000 nursing home beds in a single year demonstrates. In turn, it is placing an increased and unnecessary burden on the NHS and its staff.

Brexit and the Government’s fiscal policy will now administer new shocks to an already battered NHS workforce. No doubt the Minister would prefer it if I did not mention Brexit but I am afraid I do not inhabit the “Mary Poppins” world of many Ministers on this subject. It is now important that the public understand that far from producing an additional £350 million a week for the NHS, Brexit will seriously damage the NHS. I can find no credible economist who believes that leaving the single market and the customs union—the Prime Minister’s declared aim—can do other than reduce our GDP, with any compensating new trade deals a very long way off in the future. Companies are already making their dispositions accordingly and many more are likely to do so early in 2018.

A few success stories in the life sciences sector do not alter the bigger picture—one in which the tax take goes down as the economy shrinks and there is less money for public services. We can already see the impact of Brexit on the public finances with the £3 billion Brexit contingency fund in the Budget, and more to come to pay a divorce bill somewhere north of £40 billion—unless the Minister has some better figures.

We have discussed on several occasions the impact of Brexit on the supply of EU staff to our NHS and social care system. The total failure of this Government to provide a cast-iron commitment to EU staff working here about their future in the UK has led to a worrying exit of valued staff from our health and care system. This outflow is likely to increase further and faster in 2018. Wise heads in the NHS are already trying to plug the gaps from other sources but this will be a big ask in the short term, and the cost of replacement is likely to be greater than retaining those staff who have been lost. Our long-term failure to become more self-sufficient in the staffing of our health and care system will be seriously exposed by Brexit. Staff account for two-thirds of the costs of running the NHS and we will have to pay more than now to recruit, train and retain staff. This will be a big financial pressure, which has not been reflected in the Chancellor’s Budget.

Finally, I turn briefly to fiscal policy. The Office for Budget Responsibility’s assessments accompanying the Budget show economic growth declining, poor national productivity and an inflation rate much higher than health and care spending. The Chancellor continues his predecessor’s obsession with reducing the national debt. Despite this—what I can call only—austerity fetishism, the Government have missed all their debt reduction targets, continuously damaging public services into the bargain.

This Budget falls a long way short of a credible response to the challenges that the health and care system faces for the rest of this Parliament—always assuming that the Government last that long. Most seriously, there was no relief for adult social care, which is now massively underfunded after a 25% cut in real terms since 2010. The promised Green Paper on social care will now not appear before next summer, having been promised for this autumn. Meanwhile, our elderly and disabled population can expect in many parts of the country to have reduced access to social care services, as more providers exit the publicly-funded part of that sector. This will put further pressure on the NHS.

Apart from £10 billion of capital in the Budget, mainly, I suspect, from NHS land sales, the Chancellor has provided an extremely modest revenue increase for the NHS. There is £350 million—again, £350 million but only for a whole year—in the current year. There will be another £1.6 billion in 2018-19 and a further £0.8 billion in 2019-20. This falls well short of covering the likely cost of inflation over the period. The black hole in the NHS budget at the end of this Parliament is expected to be at least £20 billion.

My understanding is that any pay increase for staff in this period will depend on a productivity deal. Having tried to negotiate productivity deals with the NHS unions in the past I can assure the House that this is a notoriously difficult thing, both to achieve and to satisfy the Treasury that you have done so. In practice, if some staff are to get more it is highly likely that others will get less, unless the Government put in much more money, which currently looks highly unlikely. We now have an NHS workforce who have had the best part of a decade with capped pay increases, often below inflation, and now face a period of great work pressure, with inflation of around 3% a year and no certainty over their pay. This seems a bit like being a boxer who thought he was in a 10-round bout but now finds his bout is one of 15 rounds.

In conclusion, the Government’s 70th birthday present to the NHS seems to be a few bandages for the wounds, continuing short rations and no investment in reform. To quote the Royal College of Physicians, the NHS will remain, “underfunded, underdoctored and overstretched”. The enthusiastic Brexiteers now need to reflect on the consequences of what they wished for.

My Lords, I congratulate my noble friend Lord Clark not only on securing this debate but on his tenacity on this very important subject of NHS staffing. I endorse all that he said about the potential difficulties into the future—the near future of an institution which is so dear to so many of us and to which many, like me, owe their lives.

As my noble friend reminded us, this week has seen renewed fears about the safety of the care provided in our accident and emergency units, and other units, because of the lack of fully trained staff. There was also a disturbing statement earlier this week about the state of maternity services and the shortage of midwives. But I am going to widen this debate, as others have done, by focusing on another issue which fundamentally affects the efficiency—indeed, the very existence and continuation—of the NHS: social care. We need to consider other major workforces in conjunction with discussions about NHS staffing levels. I think there are three separate ones: those who work in the social care sector, the unpaid family carers, and the staff and volunteers in the charitable and voluntary sector.

It is simply impossible to consider anything to do with the running of the NHS without looking at the social care which precedes, follows or substitutes for NHS care, especially hospital care. Lack of adequate social care means more pressure on hospitals—often unnecessary pressure, as most people prefer to be cared for in their own homes; and if given proper support, they never go into hospital in the first place. Moreover, the levels of readmission rates if people are discharged without proper planning and follow-up are truly shocking, and we must be concerned about the pressure which families face if they are not given proper support with the care that most of them are only too willing to provide.

I have been concerned with social care for more than 30 years and have lost track of the number of times I have heard Ministers and others say that health and social care must be considered together, that we must have integrated services and that we must have staff who work across both disciplines. I have heard the noble Baroness, Lady Emerton, say that on many occasions. I thought it was axiomatic, but how wrong I was was proved by the Chancellor in his Budget last week. I could not believe that he failed to mention social care once. There is overwhelming consensus that the care system for older people and disabled adults is in crisis, but the Chancellor simply left it out.

Social care, which is always means tested, as we know, is provided by councils whose grants have been cut, and as a result the spending on social care has fallen by 30% in some areas since 2010. Three independent think tanks have produced a joint estimate that last week’s Budget will leave a £2.5 billion funding gap by 2019. Already, 1.2 million people are not getting the care they need, even with the enormous contribution of the 6.8 million family carers. The vast majority of care and support is provided not in hospitals and care homes but behind closed doors by family, friends and neighbours, and this is another huge workforce that we have to consider when we look at staffing levels in health and social care. Your Lordships will be fed up with hearing me refer to the value that this workforce provides but I am going to say it anyway—it is £132 billion every year, the cost of another NHS.

The number of people providing unpaid care has increased by about 1 million over the past 15 years, from 5.8 million to an estimated 6.8 million. It has far outstripped population growth. The number of carers grew by 11% over a decade. Families are caring more, not less, and therefore it is not good to hear Ministers even glancingly say that families should be taking more responsibility, because they could hardly take more than they are doing. Two years after the Care Act put in place stronger duties on local authorities to support carers, those new rights are not improving the lives of many carers in England. Carers’ assessments, which were put in place to look at the impact of caring on carers’ health and well-being, are too often failing to be put in place, and breaks and support are just not there. Some 40% of carers responding to Carers UK’s State of Caring 2017 survey said that they had not had a day off for more than a year. Imagine that, not having a day off for more than a year. In the context of this debate, the high rates of women carers and those in their 50s who are employed within the NHS means that supporting carers at work is particularly important for the NHS. Earlier this month, the Health Secretary himself highlighted the importance of flexible work and care leave for those juggling caring and working in the NHS.

The Autumn Budget did not provide additional support for social care in the short term to address the social care crisis and the predicted funding gap which I and others have mentioned, of £2.5 billion. The Chancellor offered a short-term fix to the NHS in his Budget—a sticking plaster, as it has been called—but did absolutely nothing about the long-term sustainability of health and social care funding. Sarah Wollaston, the chair of the Health Select Committee, said:

“We are failing to take the long view and see how serious the situation is. Health and social care is like a balloon—if you squeeze one part, another part pops out. The idea that you can fix the system in this way is nonsense”.

So here we are again. We have been here many times before, and it still seems many miles away from a solution to these problems. The history of our attempts is not edifying. Different parties calling each other’s proposals a death tax or a dementia tax is not helpful, and there have been endless commissions, royal and otherwise, all of which are languishing on the shelves of various Secretaries of State. The Minister will tell me that another consultation on social care funding is pending. My reaction? Oh please, not another one. Since 1997, there have been four independent commissions and five government papers on funding reform. As I said in my contribution to the debate on the Queen’s Speech earlier this year, we know the questions—we just need the answers.

I understand that the Government have now abandoned their commitment to the Dilnot commission proposals. Are we to start again then from scratch? Is all the work that the noble Lord, Lord Warner, and others did going to waste? Can the Minister please enlighten us? Have the very welcome plans for a carers’ strategy gone to waste in rather the same way? We have been working on that for some time, but we now understand that it will be rolled up with the social care consultation, which itself has been delayed, as the noble Lord, Lord Warner, reminded us. How the First Secretary of State could announce a consultation on proposals to reform social care without mentioning the contribution of 6.5 million carers is, frankly, beyond me. Discussions about a refreshed carers’ strategy have been going on for more than two years, and 6,000 carers sent in their views, at the Government’s request. Will the Minister tell me what is happening to those views, submitted by carers in good faith?

I know that last week, for Carers Rights Day, the Minister in another place announced there would be a carers’ action plan in the new year. That is a very welcome, although suspiciously late, initiative—perhaps to correct the unacceptable omission in the announcement by the First Secretary of State. None the less, I do not want to be churlish, and it is very welcome. But can the Minster tell me more about this proposed action plan and how carers and their representatives will be involved?

Finally, I want to refer to the workforce which operates in the voluntary sector. In the field of health and social care, charities are major players, providing care, developing innovative solutions to long-standing problems and representing those who have difficulty speaking for themselves. They often provide such services under contract from the local authority or a health agency, and are increasingly struggling to do so. As the Select Committee on Charities, which I had the honour to chair last year, said,

“there has been pressure on charities to reduce ‘back office’ costs and an increasing expectation that all money donated should go to the frontline … Charities cannot operate unless their core costs are met … commissioners should have regard for the sustainability of the organisations which they commission … and … realistic and justifiable core costs should be included in contracts, just as would happen in the private sector”.

Nobody would question that in the private sector.

My committee also recommended that the Government need to improve the way they consult the charity sector when developing new policies. We said:

“Poor consultation and ill-thought-through policy proposals have caused serious unease and disruption to the work of charities. We recommend that the Government reviews its approach to engagement with the charity sector before policy announcements are made, with a view to ensuring that charities feel better informed about legal changes which may affect them and have a greater opportunity to provide input on new policies”.

Although I still await the government response to the Select Committee’s report, I am glad to note that the Government have accepted this recommendation and that the Minister in another place has announced a cross-departmental initiative to improve communication. I am not expecting the Minister here to be able to respond to that, because I dare say it will not be in his brief today.

I support entirely my noble friend’s concerns about the NHS workforce but ask that the Minister also take into account the urgent needs of the social care workforce, including the unpaid carers and those who work in the voluntary sector.

My Lords, I too am delighted that my noble friend Lord Clark of Windermere has secured this very timely debate. I agree with every single word, I think, that he said. Given my own nursing background, I will perhaps single out from among the other speakers the powerful speech by the noble Baroness, Lady Emerton. She touched on a lot of extremely important matters, and the news that she may shortly be retiring from this place will leave the House much worse off when it comes to dealing with very important health matters, particularly nursing.

There are lots of warm words about nursing and lots of compliments for the work of nurses, midwives and health visitors, and this is something that Ministers are only too happy to join in with. We had it from the Chancellor in his Budget speech in the last few days, when he said:

“Our nation’s nurses provide invaluable support to us all in our time of greatest need and deserve our deepest gratitude for their tireless efforts”.—[Official Report, Commons, 22/11/17; col. 1054.]

Nobody could argue with these words, but nurses and other health staff were expecting something more when it came to the rest of the Budget speech. The scrapping of the pay cap was announced, I think, last October. The widely expected nod in the Budget to a decent, unconditional, fully funded pay rise did not materialise. Instead, any increase above a miserable l% seems to be conditional on changes to the Agenda for Change pay structure.

I agree that there may be some aspects of that structure that might need to be looked at, tweaked or updated, but the real suspicion is of course that the Government want to reduce or remove payments for unsocial hours, and that they may want to deal with issues about so-called automatic increments and put new bars to progression on the incremental scales. We have already heard about issues of productivity, and I agree with the noble Lord, Lord Warner, that any negotiations with the staff unions that propose taking some of these conditions of service away are going to be extremely difficult.

I also do not know, and would like to know from the Minister, what is meant by productivity. How do you measure a nurse sitting down and talking with a patient? Are they supposed to be on the move every minute of every hour? Nurses, midwives, health visitors and most other health staff are working at full pitch, and I do not really know what is meant by productivity increases. I hope that the Government and the Secretary of State are not setting up the staff side for blame if they fail to reach agreement on some of these proposed robbing Peter to pay Pauline suggestions that may be coming forward. I can hear it now: “You would have got a bigger increase, but the wicked staff side failed to reach agreement with us”.

I have been around the health service and health service trade unionism for all of my working life until I came into this place. There have been many ups and downs and issues in nursing morale over the years. We have had good times, better times and a lot of bad times, but I am not alone in saying that it is worse now than I can ever recall. Pay and grading is of course one of the issues that affect nurse morale—how could it not be when pay is something like 14% lower in real terms than it was in 2010? It is an important reason why nurses leave the profession. Nurses cannot pay their bills, and in some cases need to go to food banks.

However, as soon as we ask a Parliamentary Question about nursing shortages, pressures or pay, what do we get? With the greatest of respect to the Minister, what we get are the formulaic, boiler-plate Answers telling us that we have X more nurses than we had in 2010 and have created Y more training places, and that pay is for the independent NHS Pay Review Body. The review body used to work reasonably well and held the ring between the Government—the Department of Health—and the staff side fairly well before it was effectively captured by the Government’s freeze and then the 1% pay cap.

We need to unpack these ministerial Answers. There may be more nurses now than there were in 2010, but that takes no account of the growing demographic change in the population. There are more elderly people than ever before, and that means more co-morbidities. There have been huge advances in medicine and surgery. We have fewer acute beds in this country than most OECD countries. For example, Germany has over six per 1,000 population, while we have less than 2.5. Perhaps that is why ambulances are queuing for far too long outside A&E departments, patients are not seen within target times, patients are on trolleys in corridors and, as we have heard in this debate, patients are sometimes discharged inappropriately early or in the middle of the night, without adequate provision at home, so that room can be made for the more acutely ill patients waiting in A&E.

It is not therefore surprising that there are huge pressures on nurses and other staff when on duty. There are 40,000 vacancies for nursing staff in England alone, and that takes no account of increasing shortfalls in the other UK countries. It is therefore not surprising that some research tells us we have the highest nursing workload and consequent burnout in Europe. That does nothing for staff morale either.

Then there is the hopeless funding of social care. How much did we hear about social care in the Budget? “Hopeless” seems to me to be the operative word because, without significant investment in social care, the future looks grim. That in turn adds to the pressures on the health service.

Ministers are fond of referencing 2010. In 2010, we had over 8,000 nurses working in social care, but there are fewer than half that number today, while nursing homes are having to close or reregister as care homes. The continuing lack of investment in social care is going to put even more pressure on the hard-pressed NHS, despite the additional funding that, while welcome, will be nowhere near enough to avoid the continuing pressures and problems. Some 40% of the funding needed is all that was offered—better than nothing but not good enough, as the funding asked for by Simon Stevens would only have returned us to the level of increases that we had in the first 60 or so years of the NHS.

A more recent but very important matter affecting the retention of nursing staff is the dramatic reduction in the funding for continuing professional development. We have already heard the figures: the budget, which was £205 million, has been chopped down to £83 million. Part of continuing professional development is the requirement that all nurses revalidate their registration every three years, but by far the largest part of the funding is needed to develop nurses and nursing as well as to bring in new roles. Why put the brakes on preceptorship for newly qualified nurses as well as the career development that is so important? Employers cannot now develop programmes for A&E, for operating theatres, for district nursing or for advanced practice in anything like the numbers that are needed because of the huge disinvestment in CPD. I understand that the Government did not reduce CPD for doctors, so why did they do it for nurses? Can the Minister explain the disparity between the ways in which the two professions have been treated? These are but some of the reasons why members of the nursing profession are unhappy.

I turn to the matter of joining the profession in the first place, where again we have had a huge disinvestment, this time by replacing the bursary scheme with student loans. We have heard much about how this plan is going to increase the number of university places available by not having a capped commissioning system; we are told that it would give students much more money. We heard some of that from the noble Lord on the Front Bench yesterday. Universities were up for it, at least initially, because they are in a marketplace and the prospect of more students brings in more money. Perhaps the most important reason is the fact that the Treasury hopes that, by introducing the wheeze of ending bursaries, it will save £1.2 billion. Is that fact or fiction? After all, I cannot see where that £1.2 billion has been reinvested in the NHS.

It may be that many nurses will not pay back their loans because, if they stay in the nursing profession in the health service for 30 years, they are unlikely to earn enough to do so, but what of the effect on the potential recruits? It is a long time since I started nursing, but in Scotland we could start nursing at 17 and a half. I recall that two or three out of that first year could possibly have been referred to as mature students; the rest of us were all youngsters. Similarly, in my post-registration training south of the border, we had a nursing cadet scheme where most people came in at 16 as cadets and commenced nurse training at 18. Mature students were almost unknown. It is a totally different situation today. Many students are mature or have family responsibilities. I cannot see how they would want to come into the profession now, with the risk of being saddled with a student loan for many years to come. It is a perception thing, and it is extremely important that the Government keep the matter under review and carefully monitor it.

There is one bit of good news that I would like to touch on, and that is the development of the new nursing associate. The measure is long overdue and, provided that it is developed correctly, it will give an opportunity for many who do not want to do the full degree course to become a registered nurse. That is something that my old union, the Confederation of Health Service Employees, campaigned for at the time of the ending of enrolled nurse training, but it did not happen. Still, what goes around comes around.

My concern here is that we do not return to the situation that we had with enrolled nurses and that the substitution of the nursing associate for the registered nurse becomes a fashionable thing, particularly with pressures on finance. The awfulness of what happened in Mid Staffs is not so long ago that it can be erased from health boards’ corporate memory. We know that the fewer the registered nurses, the greater the mortality risk. I do not want to see any substitution here of registered nurses by nursing associates.

I just wish we could stop this nonsense of nursing associates already being referred to as “associate nurses”. It is important that they are going to be registered by the Nursing and Midwifery Council, but a nursing associate is not a nurse. I wish we could regulate and protect the word “nurse”. The phrase “registered nurse” is protected, but the word “nurse” is not. We have health trusts applying the label “advanced nurses” to people who have never seen a bit of nurse training in their lives. That should not happen, and it is something I would like to see the Government getting a grip of.

My time is up, but there are many issues that have to be addressed if we are to resolve some of the issues that have been raised in today’s debate. I forget who it was who said it, but if these things are not dealt with then rivulets of discontent could reach flood proportions. I hope not—we have been there in the past and I do not want to see it in the future. There is much work to be done, and I hope the Government can get a grip on some of these difficult issues that we face.

My Lords, I thank the House for the courtesy of allowing me to speak in the gap. I thank the noble Lord, Lord Clark, for bringing this timely debate to the House today. I refer to my interests as listed in the register and as being a member of the Select Committee on the NHS.

I welcome the statement by the Secretary of State for Health, Jeremy Hunt, that the Government recognise that it was not sustainable after seven years to carry on with the 1% rises or pay freezes. As we have heard today, we cannot expect NHS staff to go the extra mile if the money falls short; eventually, people will vote with their feet. So I am pleased to hear proposals for benefiting patients, from the announcement in the Autumn Budget of £6.3 billion of new funding for front-line NHS services and upgrades of NHS buildings and facilities to the creation of the “Homes for Nurses” scheme, giving a new right for the NHS worker to have first refusal on affordable housing, which would be generated through the sale of surplus NHS land, with an ambition that around 3,000 NHS workers would benefit. This is very much to be welcomed; our NHS staff are the backbone of the service, so it is important that we put first the people who are central to the delivery of high-quality care that is safe, effective, caring and responsive. I also acknowledge the 25% increase in placements for student nurses to increase the number of homegrown NHS staff, to reduce the reliance on expensive agency nurses, and to prepare ourselves for Brexit.

NHS staff need to feel safe and valued, with family-friendly policies, and there is a need to create a healthy morale to sustain a committed workforce. Factors that really influence staff retention include access to learning and development opportunities, a caring environment and a tough approach to violence towards staff. Retention of staff is a must, and the key to the sustainability of the NHS, while the fact remains that more has to be done to replace those who have left. I therefore welcome the launch of a new major programme to improve staff retention. It would appear—and it is regrettable—that more focus should have been on training the existing workforce, opening up the possibility of new opportunities leading to career progression. Training models in the health service have changed between 1947 and today, and will surely be radically different in 10 to 25 years’ time. We must not lose momentum on innovation and technology in order to have a continuous, dedicated and well-qualified workforce fit for the future.

Health trusts must also welcome learning from other hospitals, or look at mergers or working more closely together, sharing precious data in helping them raise their game in order that good leadership can drive continuous improvement in patient outcomes and productivity. We see staff working well in structured teams, fully engaged and supported to make changes to how they deliver that care, and able to make those changes to improve quality and productivity. It is essential that trust boards consider feedback from front-line staff. Trusts must make themselves great places to work, with job satisfaction, career progression and continual training as one. The importance of understanding what staff want cannot be understated.

Finally, I welcome, too, the Government’s endorsement of the NHS Five Year Forward View, funding it with £10 billion more a year for the health service by 2021. However, even with that funding, the health service remains under pressure, with more people than expected using the service last year. It is worthy of note that 2016-17 saw the NHS treat 2.9 million more A&E patients than in 2010. That is all thanks to our fantastic NHS.

My Lords, I join other noble Lords in thanking the noble Lord, Lord Clark of Windermere, for calling this debate, and other noble Lords for their excellent, expert contributions. I shall, in the main, address issues around nurses but much of what I can say will apply to doctors, other clinicians and healthcare professionals.

The Government’s policy has been to take the view that if you pay less you can afford to employ more with the same money. This might be all very well in an industrial context. If you need a commodity to manufacture a widget and you can get it cheaply at the same quality, you can get more widgets for your money. However, we are talking not about manufacturing but about the men and women that the state employs to care for those in our society who are ill. Many of those staff have years of training or experience, and some of them could earn more in the private sector or in health services abroad.

It is the people whom the noble Lord, Lord Clark, has asked us to consider in this debate, but first we must look at the money. I have a paragraph spelling out the numbers but the noble Lord, Lord Warner, has beaten me to it and I shall not repeat them. They should be taken as read. However, the wider financial pressures in the NHS were not addressed adequately in the Budget. Before the Budget there was an assessment of the NHS financial requirement for the future from the respected trio of the King’s Fund, the Nuffield Foundation and the Health Foundation, indicating that £4 billion was required. The Chancellor committed less than half of that. Undoubtedly, part of the recruitment and retention problems the NHS is experiencing is linked not only to pay but to the pressures that staff are put under to continue delivering high-quality services with insufficient resources.

For the record, the Lib Dem policy of a penny-in-the-pound rise on all income tax bands and dividends would raise around £6 billion a year. This would be a hypothecated tax and would go some way to allowing the NHS to recover and grow again. As many Peers have said, we all waited in vain during the Chancellor’s speech for a mention, no matter if brief, of social care. Can the Minister indicate how the Government anticipate supporting the care sector to grow and relieve the NHS of those who are in its beds when there is no further need for healthcare? Is the market expected to address this? It is local government’s responsibility to shape its local markets. This seems patchy at best. Will the Minister tell the House where local authorities could look to see good practice in this regard? Without addressing the issue of those unable to move out of acute care to either a care home or a package in their own homes, productivity will be a difficult ask.

We know that demand will rise, that the ageing population is growing and that treatments to manage and cure illnesses will improve, but often at increased cost. What is new? What might be done to narrow the gap? We look at the women and men who so valiantly and professionally care for our sick. I have spent some considerable time recently in my local acute hospital and then a local community hospital where my mother—frail, demented, and very elderly with failing heart, eyesight and hearing—has received professional care and attention. She was typical of most in her ward, and I watched as she became the policy stereotype whom we debate here. Those teams, nurse-led, are without a doubt stretched. They went home after their shift exhausted but I was certain that they knew what “excellent” looked like and they strove to deliver it. They are all in the mould of the noble Baroness, Lady Emerton, whose wise words we will indeed miss.

However, we know that anecdote should not deliver policy but that sufficient evidence should inform it. I therefore offer the staff survey carried out by the NHS last year. It showed that 36.7% of respondents reported feeling unwell as a result of work-related stress. In 2015, a different survey carried out by the Guardian found that 61% of healthcare professionals reported feeling stressed all or most of the time. Whichever number you take, it is too many and is good for neither recruitment nor retention, nor morale.

The Government’s continued insistence on a pay-rise cap of l% for public sector workers did untold damage to recruitment, retention and morale among the NHS workforce. In July, the BBC reported that more nurses and midwives are leaving the profession in the UK than joining it, for the first time since 2008. The number registered in the UK fell by nearly 1,800 to 690,773 in the year to March. Full Fact reports that, overall, nearly 35,000 nurses and midwives left the Nursing and Midwifery Council’s register in 2016-17. This does not bode well and has to be addressed. We need to value our staff, and I welcome the Chancellor’s statement that he will remove the cap on public sector workers’ pay and review the Agenda for Change pay awards—albeit conditional on increased productivity, staff recruitment and retention. This is the nub of our debate.

Agenda for Change receives recommendations from the NHS Pay Review Body on recommended pay uplift. It is an independent body. Will the Minister describe the mechanism by which an independent body can make recommendations that appear to be predetermined by the Chancellor? For productivity, we need to look at our staff—from the cleaners to the consultants and, importantly, to the boards of our NHS trusts—to examine the bottom line of the balance sheets differently. They should ask not what can be cut but what can be done differently. They need to look at all their staff as agents of change and look at what other trusts do differently. Each unit needs to become a learning unit, whether that is A&E, a children’s ward or the chief executive’s office. They need an overall aim, made up of small and achievable bite-size aims. They need to measure progress, be proud of their achievements and be willing to share them.

This is nothing new, but people need to be given time to think about what they do, and permission to get off the treadmill and consider what small changes would make a large difference to their working practices and the care of their patients, and we should reward shared innovation. If we crack this, productivity should improve, as should morale and retention—although retention also depends on reward.

The Health Education England CPD budget has been cut from £205 million in 2015-16 to £83.5 million in 2017-18. What are health professionals expected to do to keep up to date? The report from the Nursing and Midwifery Council last month states that nurses and midwives are already taking themselves off the register. The Minister has already given the House an assurance that the Government do not intend to recruit from the third world, so how is this to be resolved in the short term? We have had long-term answers, but it is a short-term problem. What plans are in place to entice back nurses working elsewhere and to train more? What sorts of gaps are anticipated? What is current thinking?

Attracting people to train as a nurse would be easier if the bursary were reinstated. It is not just about money. It sent the wrong message to bright young people attracted to a profession that is not well paid. It needs to be reassessed and reinstated.

For a Lib Dem, I have done quite well speaking for so long without mentioning Brexit. The NHS has had years of employing staff from our fellow EU states at all levels of the NHS—and, indeed, in health research. Yesterday, the Association of Medical Research Charities was having a Westminster day meeting parliamentarians from both Houses. I met four chairs who were really alarmed at the implications for medical research outside the EU. They told me that they had met the Minister but were still in need of assurance. Where do the Government stand on that?

To increase recruitment and retention, we need to raise morale and involve staff in the solution to the problem. We need to pay them a fair wage. We need to continue to encourage and fund professional development. We need to cast the net widely to recruit at home and abroad, because we need an NHS prepared for the next 70 years and the challenges, which the noble Lord, Lord Warner, outlined, that that will surely bring.

My Lords, it is a great pleasure to thank my noble friend Lord Clark for allowing us to have this important debate. I also pay tribute to the noble Baroness, Lady Emerton. It was very good to hear her speak today. She threatens retirement, but let us hope that is a little time off yet.

My noble friend spoke in a passionate, informed way of the considerable challenges facing the National Health Service and its workforce, and the link between the workforce challenges and the problem of NHS performance at the moment. As my noble friend Lord Pendry said, the NHS faces its most difficult time since its inception. Not only are targets being missed but the key quango, NHS England, effectively says that it will no longer attempt to meet some of those targets, including the 18-week target.

My noble friend Lord Clark spoke of statements emanating from the leadership of NHS England that it will have to ration treatment. I put it to the Minister that paragraph 16 of the board papers published this morning by NHS England states:

“Our current forecast is that—without offsetting reductions in other areas of care—NHS Constitution waiting-time standards in the round will not be fully funded and met next year”.

I remind the Minister, because we debated this in September, that meeting the core targets, including that of 18 weeks from referral to treatment, is a legal requirement under the NHS constitution. I also remind him of a statement made by the Government on the morning of our debate on 6 September this year. It said that the 18-week standard,

“remains a patient right, embedded in the NHS Constitution and underpinned by legislation. We have no plans to change this”.

Will the Minister today repudiate the action that the NHS commissioning board is being recommended to take, signal to the House that the constitution and associated regulations will be amended to allow NHS England to not meet the standard, or produce the funds so sorely needed to ensure that the NHS can meet it? It is no good for Ministers just to shrug this off; it is a matter for which they must account to Parliament.

That is just one example of why we have such huge workforce pressure. I thought that NHS Providers summarised the situation very well when it talked about mounting pressure:

“Rapidly rising demand and constrained funding is leading to mounting pressure across health and social care”.

My noble friend Lord MacKenzie spelled that out well. It also said that most provider trusts,

“are struggling to recruit and retain the staff they need”,

that the supply of new staff,

“has not kept pace with rising demand for services and a greater focus on quality”,

and that,

“recruiting and retaining staff has become more difficult as the job gets harder, training budgets are cut and prolonged pay restraint bites”.

It also states:

“Even if there were no supply shortages of staff, and provider trusts had no difficulty recruiting and retaining staff to work for them”,

many would,

“be unable to afford to employ the staff they need to deliver high quality services”.

No doubt we will hear the Minister peal out some statistics showing that there have been some increases in staff between now and 2010, but that is not the whole story. First, he must take account of the increase in demand on the health service over those seven years. Secondly, in 2010, the coalition Government made disastrous decisions to cut, in particular, nurse training places. In a panic, they have had to reverse that decision, but we are behind the curve in relating staff numbers, the number of staff training places and the way services are going. The decision to scrap bursaries has proved a disaster—disastrous to the wretched universities that proposed it, because they do not have more nurses coming in, as they thought they would, and a disaster for the Government. It must be reversed.

On pay policy, my noble friends Lady Donaghy and Lord MacKenzie spoke very well about the impact of pay restraint on low-paid workers. The pay review bodies are hardly independent in that it is clear that they have now been told they can go above 1%, but there will be no money to pay for it. Independence? What independence do they have? What prospects are there for so many NHS staff to have decent pay in the future?

I also raise something I find very disturbing. First, there is the attack by Jeremy Hunt on NHS staff over compensating for working anti-social shifts. Apparently, he thought he did so well over the junior doctors’ negotiations that he will bring the same great skill and leadership to the other staff groups in the health service. That will certainly improve morale, will it not?

I also raise with the Minister a disturbing trend being forced on NHS foundation trusts by NHS Improvement, which is designed to take thousands of staff out of NHS employment and, as worrying, out of the NHS pension scheme. This is a growing trend to set up wholly owned subsidiary companies to run a lot of non-clinical services within trusts. Clearly, it is a VAT fiddle—it is designed to reduce VAT payments—although the DH has to make up to the Treasury the VAT return, so it is a false economy by the health service. Staff who transfer to the company retain their employment rights, terms and conditions and NHS pension, but new employees have no such guarantee whatever. I gather that NHS staff who are really being forced to transfer to these subsidiary companies are being encouraged to opt out of the NHS pension scheme in return for a bribe of a higher wage rate. I find it deplorable that this can be encouraged by bodies responsible to the Minister. Staff are being encouraged to come out of the NHS pension scheme. That is absolutely disgraceful. I hope the Minister will say today that that will be stopped.

On resources, what can I say? My noble friends Lord Pendry and Lord Clark clearly think that the bung put in by the Chancellor is insufficient. The Institute for Fiscal Studies said that the NHS was in the middle of its toughest decade ever. It said that after accounting for population growth and ageing, real spending had and would remain unchanged for years. Sir Bruce Keogh, medical director of the NHS, said after the Budget that, “longer waits seem unavoidable”.

The King’s Fund, the Nuffield Trust and the Health Foundation, in their post-Budget analysis published two days ago, said that next year the NHS will not be able to meet standards of care and rising demand. Resources are a major issue in relation to the workforce. So, too, as my noble friend Lady Donaghy said, is staff affection for the shambolic system the coalition Government imposed on the NHS in 2012. We knew it would be a disaster; we said so for 15 months in your Lordships’ House. They determined to go on with it and we have ended up with a hugely fragmented leadership, wholly inadequate commissioning and rampant instability in providers. We have reached a point where the Secretary of State himself disowns the 2012 Act. The whole purpose of setting up STPs is basically to circumvent the rules of the market within that Act. No wonder the staff feel unhappy when leadership is so fragmented and hopeless. When will the Government legislate to legitimise what is happening? The 2012 Act is clearly being ignored.

My noble friend Lady Pitkeathley focused very well on social care, of which there was nothing in the Budget. The Green Paper has been put into the long grass and I do not expect to see it for many, many months. For carers there is a whole lack of support and no strategy. No wonder the social care workforce is in such a shambles.

I am sure the Minister will talk about this: we are now promised a workforce strategy. The Secretary of State gave an interview to Health Service Journal recently, in which he said:

“My strong view, having been involved in this job for a while now, is that the big problem with workforce strategies is that both me and predecessors in my role have only thought about workforce in terms of the current spending review and that’s really what has caused us a problem in the past because we only committed to train people for whom the Treasury had given concrete assurance they were prepared to fund. We ended up with very short-termist spending reviews, sometimes they were only a year … My view is, given how long it takes to train a doctor or a nurse, you cannot have a workforce strategy that is anything less than 10 years”.

In 2010 the Government inherited a long-term workforce strategy, and what did they do? They cut it viciously.

The Minister is always fond of sermonising to me, in particular, on the economy, and why the Government did what they did. I remind him that in 2010 the economy was growing at 2% per annum and the Government snapped it off. It took a long time to recover. I also remind him of what the noble Lord, Lord Warner, said: the UK economy is incredibly fragile at the moment. We have low productivity and downward projections on growth. The OBR has revised growth down to 1.5% this year, 1.4% in 2018-19 and 1.3% in 2019-20. The IFS has described this decade of a Conservative Government as the age of austerity and stagnant wages, which it now expects to last for another decade. I say to the Minister that, with the disaster of Brexit to come, the Minister should spare us lectures on the economy.

What are we to do? What is the future? NHS Providers did a very good piece of work, recently setting out a strategy for closing the workforce gap, making the NHS a great place to work and ensuring that we have strong, effective leadership. I commend that report to noble Lords. There is an awful lot to do, and I am afraid I am not confident in the Government’s ability to do it.

My Lords, I thank the noble Lord, Lord Clark, for calling this debate and all noble Lords for their contributions. It is the first time I have had the opportunity to debate with the noble Baroness, Lady Emerton, which I hope will not be the last and that she does indeed continue contributing.

We all agree that the NHS is one of our great institutions. It spans political divides and brings people together, although apparently it does not bring together enough Ministers to satisfy the noble Baroness, Lady Walmsley. We are all rightly proud of our NHS and the staff who work incredibly hard for the good of patients. The quality and dedication of our NHS staff is why we have the best health service in the world. It is, as the noble Lord, Lord Clark, said, second to none. It is also a great privilege to have so many former NHS staff in this House speaking today, including the noble Lord, Lord MacKenzie, and the noble Baronesses, Lady Donaghy and Lady Emerton.

We as a Government do not pretend that everything is perfect, but we should be proud of the NHS’s many achievements: universal access; the progress we are making on improving cancer survival rates; transforming care for dementia and mental health; our strong primary care; research and development; and the quality of medical education and training, among many others. It is because of those achievements that the independent Commonwealth Fund recently rated the NHS as the best health system in the world for the second year in a row. Contrary to the accusation from the noble Lord, Lord Clark, I believe that this shows the very opposite: success. Of course, the NHS faces challenges, but it is doing well.

The first part of the title for today’s debate refers to the Government’s fiscal policy, so I want to begin by laying out the reasons for that policy and the actions taken within it. I will resist the urge to lecture, I hope, but I will point out the facts. In 2010, the coalition Government inherited one of the most challenging fiscal positions in the world. The Conservative and Liberal Democrat parties came together with a plan to reduce the deficit because we understood that a failure to do so would burden the next generation with debts which they had no hand in creating. It was fairness, particularly intergenerational fairness, which drove that policy.

We also understood that you cannot have strong public services without a strong tax base; and a strong tax base requires a strong economy, in which investors have confidence that the Government will be fiscally responsible and where it becomes easier to create and sustain jobs. That is what we, as a coalition and then as a Conservative Government, set out to do. Inevitably, this approach necessitated many difficult decisions, but we have now reduced the deficit by three-quarters, from 9.9% of GDP in 2010 to 2.3% in 2016-17. We forecast it to fall gradually to 1.1% in 2022-23, the lowest for 20 years. Employment is at a record high and the economy continues to grow.

As the noble Baroness, Lady Walmsley, pointed out, the greatest health policy is to reduce poverty, and having more people in work is a core part of that. It is because of those firm fiscal and economic foundations that we were able to protect and grow NHS budgets at the spending reviews in both 2010 and 2015. Furthermore, because we recognise that the NHS is under pressure right now, in the Budget last week we heeded calls for more funding, with £2.8 billion extra over the next three years to help the NHS meet its performance targets, and over the next five years a £3.5 billion programme of additional capital investment.

Several noble Lords, including the noble Baronesses, Lady Jolly and Lady Pitkeathley, and the noble Lord, Lord Warner, asked about the lack of mention of social care in the Budget. It is worth pointing out that we had two Budgets this year. In the previous Budget, in March, there was an announcement of £2 billion extra for social care. Indeed, we confirmed recently that there will be a Green Paper in the summer to take social care reform forward. It will deal with the issue of carers, as referred to by the noble Baroness, Lady Pitkeathley. I should point out that it has the continuity to build on suggestions made by Andrew Dilnot’s expert advisory group in the past.

As the noble Baroness, Lady Jolly, said, we need to look at the money. That means that funding in real terms on the health service will be £12.5 billion higher this year, £14.2 billion next year and £15.8 billion higher by 2020-21 compared with 2010-11.

Both the noble Lords, Lord Hunt and Lord Clark, cited Malcom Grant, Sir Bruce Keogh and others. I cite Jim Mackey, the head of NHS Improvement, who said, in the light of the Budget,

“news that the pay award will be funded in full is very welcome, as is additional revenue, starting this winter and over the next couple of years”.

As a consequence of the funding that we have put into the NHS, despite the necessary fiscal readjustment we had to undertake to reduce the historic deficit left in 2010, the proportion of public spending consumed by the NHS has grown. That is not an overblown statement; it is a fact, and it is a mark of this Government’s and this party’s commitment to our cherished NHS.

I understand that there are huge concerns about the long-term sustainability of the health and social care services in the future. I understand the appeal of a royal commission, convention or some such although, like the noble Baroness, Lady Pitkeathley, I am sceptical about the need for it at this time. Several noble Lords have served Governments who have had commissions of this kind—and we know what those reports are doing, as she pointed out. Therefore, I think it is important for us just to move ahead. I recognise that my department’s response to the Lords Long-term Sustainability of the NHS Committee has been too slow. I have had a useful note from my officials during this debate which will enable me to commit to publish it very shortly.

As regards the workforce of the NHS, we all know, and have recognised today, that our growing and ageing population continues to create increased demand and activity, and this means that there has been a need to recruit more staff. We have been working hard to do this. That is why, as several noble Lords have pointed out, there are some 10,000 more nurses on wards and more midwives and health visitors. Over 50,000 nurses are in training and there is an increase in medical training places. Those are the facts. A particular example of our approach is the determination to transform the NHS workforce through apprenticeships. It was good to hear the noble Lord, Lord MacKenzie, welcome the fact that we recently announced an expansion in the numbers of nursing associates. Plans will see 5,000 nursing associates trained through the apprentice route in 2018 and 7,500 in 2019. I will certainly look at the issue of naming. It is quite wrong that they should be wrongly named because the name that they have been given is specific to the functions that they perform. I shall write to him on that issue. We expect that once this new route into nursing is established, up to 1,000 apprentice nurses could join the NHS every year, benefiting staff and patients.

We had the opportunity yesterday to discuss the issue of nurse bursaries and they evoke passionate responses across the House, not least from the noble Lord, Lord Clark, whose paramount concern I know is making sure that the NHS has the staff it needs to deliver the quality of care we all demand of it. I have outlined why we made changes in the system and do not suggest that anyone particularly wants to hear me reprise that, but it was done to put nursing on a more equitable basis with other university degrees. We moved away from centrally imposed number controls and financial limitations. Furthermore, through additional clinical placement funding announced this summer and further funding in October this year, around 5,000 more nursing students will be able to enter training through funded clinical placements each year to 2020-21. I certainly take on board the point that the noble Baroness, Lady Emerton, made about looking at their training and making sure that it is as multidisciplinary as possible. As a result, in the future NHS employers, as well as those in the independent, care and voluntary sectors, will have a larger pool of highly qualified homegrown staff available.

Noble Lords asked whether the NHS has enough staff. The most recent workforce figures show something like 30,000 more clinically qualified staff working in the NHS over the last seven years. We can argue about whether that is enough but it is more than a 60% increase at a time when, as we all know, there have been difficult fiscal decisions to make. We know that increased supply is only one part of the equation, which is why NHS Improvement has launched a new programme to improve staff retention and reduce leaver rates. This includes, among other things, targeted support for all mental health providers to improve the retention rates of all staff groups within these trusts, and an intensive package of clinically led support targeted at providers with above average leaver rates for nurses. However, as the noble Baroness, Lady Jolly, said, probably the greatest way to retain staff is to ensure that they are properly paid. That is why we have introduced the new national living wage to make sure that lower-paid staff groups in the NHS and social care, whose work the noble Baroness, Lady Donaghy, rightly lauded, see increases in their pay packets, and why I warmly welcome—as did my noble friend Lady Redfern—the commitment in the Budget to end the pay gap and to fund the Agenda for Change pay negotiation package that is agreed, subject to reasonable conditions about improved productivity, which, for example, might be to do with the better use of technology and demonstrable beneficial impacts on recruitment and retention. My noble friend Lady Redfern also pointed to the recent announcement we made on using NHS disposable surplus land to provide homes for staff. Again, that is a very welcome gesture.

We also need to attract back staff who have left the profession. The noble Baroness, Lady Jolly, asked particularly about this issue. I reassure her that, since September 2014, Health Education England has supported over 3,500 nurses to successfully complete the nursing return-to-practice programme and they are now ready for employment. It has also worked with the Government Equalities Office in creating a national allied health professional return-to-practice campaign to make 300 professionals available for the workforce in a couple of years’ time.

I come to the Brexit section—we have to do it. Several noble Lords asked about the impact of Brexit. I think it would be churlish of me to point out that 80% of the vote in the most recent general election was for parties whose manifestos committed us to leaving the European Union. But, more importantly, if noble Lords look at the data on EU staff in post in the National Health Service and compare it from the month of the referendum to a year later, they will see that there was actually a small increase in the number of EU staff working in the NHS. I take this opportunity to send a message to those staff that we value them, want them to stay and want to deal with the issue of citizens’ rights with the EU as soon as possible in the next phase of negotiation.

If we want to deliver world-class staff, we need enough of them. We need them to stay in the service and have working conditions that will allow them to thrive, professionally and personally. This is why our manifesto committed us to encourage flexible working, improve health and well-being and take action against those who attack or abuse NHS staff. The NHS has to keep pace with increasing demand but it cannot do this if it is out of step with the demands of modern family life. We know that caring responsibilities are most likely to fall to women, who make up around two-thirds of the NHS workforce. As the noble Baroness, Lady Donaghy, pointed out, inflexibility leads staff to work for agencies, diverting resources away from the NHS which could be invested in the permanent workforce. I reassure the noble Lord, Lord Clark, that we are reducing spend on agencies. He was right to point to the jargon in my Written Answer to him. I was obviously having an off day and did not spot it—either that or I have gone native, but I am usually quite good at striking it out. I think the point that it was trying to make was that you can recruit agency staff, but the agencies must first be approved. However, we could certainly have expressed that better. Our aim is to discourage the use of agencies by improving the staff banks that trusts use, making it easier for staff to work flexibly, pick up extra shifts at short notice and be paid quickly. Next year, we will pilot a new network of modern staff banks across the NHS. I give noble Lords an example of how that is working. Milton Keynes had very low take-up of bank shifts, leading to a disproportionate reliance on agencies. It developed a new system, including an app, and, as a result, shifts filled within 30 minutes of being advertised on the app and agency shifts reduced from historic high levels of 600 per week down to 300. That is impressive but I think we can do more.

It is also crucial that employers pay close attention to and invest in the health and well-being of their staff. Reducing sickness absence improves productivity, the quality and continuity of patient care and saves money. That is why NHS England’s commissioning for quality and innovation initiative will allow for quicker access to a range of health services such as musculoskeletal and mental health services for NHS staff.

Bullying can be one the greatest causes of ill health and staff unhappiness and, unfortunately, we know that bullying rates in the NHS are too high. It is completely unacceptable, which is why in July 2016 senior NHS leaders and the Social Partnership Forum developed a collective call for action. We are committed to working with the health system and, critically, trade union leaders through the Social Partnership Forum to tackle violence and abuse against staff. That is a key priority.

The Government have also been supporting Chris Bryant MP’s Bill in its passage through Parliament. The Bill, drafted with the assistance of the Home Office and the Ministry of Justice, will provide police and courts with effective powers to deal with those who use violence against emergency workers. Everybody in the House will agree that it is completely unacceptable that staff should be at risk of harm, simply for doing their job. Employers have a duty of care to all their staff and must take all the necessary steps, including disciplinary action where required, to put a stop to it.

The noble Lord, Lord Hunt, made a point about subsidiary companies. I am not aware of that issue but I will certainly investigate it and write to him; I will place a copy of the letter in the Library.

In conclusion, despite the difficult but necessary decisions that this Government and the coalition Government before them had to take, NHS funding is at record levels, with more doctors, more nurses on wards and more operations being performed than ever before. Survival rates are at a record high. Last year, the NHS treated more people than ever, which was possible only through the commitment and dedication of NHS staff.

However, we understand that we cannot rest on our laurels, and that the NHS must continue to attract and keep the staff it needs to be the best it can be. Staff choose a career in the NHS not just because of pay, but because they want to help to improve the lives of the patients who rely on them, whether in hospital or in the community. We want to create an NHS in which staff want to work and feel valued for that work, where they are motivated and feel safe, and where bullying and harassment are not tolerated. With record funding and innovative policy solutions, this Government are committed to delivering that as the NHS reaches its 70th year.

My Lords, I thank the Minister for his reply. I began the debate by commenting that, having seen the list of speakers, I expected a first-class, thoughtful debate. I have not been let down. I thought that the debate was excellent. I want to single out, if I may, the noble Baroness, Lady Emerton. I felt privileged and honoured to hear her contribution. More than anything, I love the fact that she has retained the enthusiasm for and belief in the NHS that she took into her nurse training in 1953. I thank her very much for allowing us to share that. We have all certainly gained from it.

I hope that the Minister agrees that this has been a thoughtful debate. I have learned quite a lot from it and I hope that he has too. I hope that he will take up the spirit that came from three sides of this House—if we can have three sides here—because there is unease with our health service. However, we want the Government to succeed because we want the NHS to succeed.

Motion agreed.