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House of Lords Hansard

NHS and Social Care: Impact of Brexit

21 July 2016
Volume 774

    Motion to Take Note

    Moved by

  • That this House takes note of the implications of the European Union referendum result for government policies on ensuring safe staffing levels in the National Health Service and social care services.

  • My Lords, we have spoken at length about the uncertainty following the decision to leave the EU. While negotiations take place in the coming months and years, we must not forget that business continues as usual in the health and social care services, where staff care for our loved ones 24 hours a day, seven days a week. Two big stories appeared in the papers at the beginning of the week. The first was about nurses and plagiarism in universities and the second, much more cheerful one, was an opinion piece in the Daily Telegraph by Simon Stevens, the chief executive of NHS England, with which I broadly agree. However, I want noble Lords to know that I had written this speech before I read his piece, so it is not plagiarism.

    I declare my interests as listed in the register, in particular as a registered nurse in both the adult and mental health domains, a member of the Royal College of Nursing, emeritus professor of nursing at Plymouth University and the chair of the peninsula CLAHRC in the south-west. I am delighted to congratulate our current Minister, who is to continue in his role representing health in this House. I will use nursing as a lens through which to articulate my questions, but I believe that the majority of the issues raised affect all those working in our NHS and social care services, and of course the clinical research community.

    The decision to leave the EU leaves us with serious uncertainty on the current and future supply of the lifeblood of our NHS, the private, voluntary and social care sectors—namely, the workforce. That decision, together with what I had written was a proposed move to a loans system for nursing and other healthcare students, could pose a dangerous threat to the quality of patient care. This morning the Government announced that they will move to that loans system, and I will return to that later in my remarks.

    In March 2016, the HSCIC figures for England showed a headcount of nearly 320,000 nurses and health visitors, 26,000 midwives, nearly 20,000 ambulance staff and almost 150,000 scientific, therapeutic and technical staff. At the same time in Scotland the headcount was approximately 60,000 nurses and midwives. Out of those numbers it is estimated that between 5% and 10% of the staff working in these roles are from other EU countries, clearly with variations by professional group. There are currently more than 33,000 nurses who trained in the EU registered to work in the UK and in 2015-16 alone there was an increase of 9,000 EU-qualified nurses on the NMC register. The latest GMC figures show that more than 30,000 doctors are working in the UK whose primary qualification is from another EU or European Economic Area country.

    EU nationals play an integral role in delivering safe, high-quality care now more than ever, and our NHS is particularly dependent on these crucial staff. Yet EU nationals already working in these services are worried about what their future holds and whether they will be able to continue to make a valuable contribution to our society. Likewise, patients and users of our NHS have the same questions. Let me be clear: these professionals are highly valued and we simply cannot do without them.

    Noble Lords may have heard of incidents since the referendum in which some health professionals from outside the UK have been subjected to racial abuse while caring for patients. No member of staff should have to tolerate abuse in the workplace at any time. Ambiguity around the immigration status of health professionals is not helping matters, and I ask the Minister to look at how quickly we can reassure them. Staffing levels, recruitment and the retention of nurses in the NHS continue to lag behind the number of staff we need to guarantee the highest levels of safe care for people using the NHS. In Wales, and soon in Scotland, staffing levels are enshrined in law. I urge the Government in England to look at this option carefully for public protection in the post-Brexit era.

    Following the Francis inquiry into standards of care in Mid Staffordshire, the public were assured that financial considerations would not be put above the need to provide high-quality care and maintain good standards, which of course are dependent on the number of staff employed. The relationship between the staffing ratio of nurses to patient outcomes is well evidenced through international research: the higher the number of nurses, the better patient outcomes are, including patient readmissions after discharge. Yet mental health services in particular suffer from chronic understaffing and the number of specialist mental health nurses has fallen by 10% over the past five years. There are strong arguments for adequate nurse-to-service-user ratios to ensure the proper development of therapeutic relationships in mental health services. It is also clear that the higher the number of experienced registered nurses on duty, the less restraint and seclusion are used, which I argue is an indicator of quality care. While the introduction of the new nursing associate role in England is widely supported, current research suggests that the role will be no substitute for registered nurses, but a supplement to care delivery.

    Many people who voted to leave the EU did so because they believed that extra resources would be allocated to the NHS as a result of savings in EU contributions. I argue that further funds should be found to train, develop and retain professional staff in the NHS and social services. In this context, I return briefly to what was the Government’s proposal but is now going to happen: the replacement of NHS bursaries by student loans for nurses and other health professionals. This idea began before the result of the referendum was known. It is an increasingly risky move during this period of turbulence through all the changes with the EU. But now that it has been announced, we must make the best of it. Nurses are struggling to make ends meet as it is. We have heard of some student nurses using food banks. Any reforms to the student bursary structures need to ensure that tomorrow’s workforce is not saddled with a lifetime’s debt, which the Government have already acknowledged is unlikely to be fully repaid given the average nurse’s lifetime earnings.

    The Royal College of Nursing found that 40% of London’s nurses expect to leave the city by 2021 because housing costs are so high. The additional costs of even small monthly student loan repayments for nurses will make life harder for them despite working full-time. Tomorrow’s nurses serve as a good example of the very people our new Prime Minister wishes to consider when making future policy decisions. I, really more than anybody else, hope that the introduction of the loan does not prove to be a mistake. Any new model of funding should have been piloted before we ran it right across England, to ensure that it would result in an increase in the number of nurses taking up training places.

    However, as a pause is not feasible, which many noble Lords know I would have liked, there remains a critical need to ensure the security of the future workforce supply—a task that I believe has become more difficult since 24 June. In that light, I shall touch briefly on three areas of risk on which there is widespread consensus from all organisations in the nursing world.

    First, will the Government commit to protecting the postgraduate pre-registration courses that are so valued by employers and enable some of our best and brightest graduates to fulfil specialist careers in the NHS? Perhaps we should develop something similar to Police Now or Teach First. Secondly, will the Government commit to measures to support students who might otherwise be deterred from joining courses, ensuring that childcare grants do not disadvantage single parents, and recognise the particular challenges facing some professions in areas of nursing where student recruitment is still not buoyant, such as podiatry and learning disability nursing?

    Thirdly, will the Government recognise the extra costs that healthcare students incur from essential aspects of their courses, in particular the travel and accommodation expenses associated with placements, particularly in rural areas, occupational health and uniform requirements? Linked to this, will they fund universities directly to purchase high-quality placements for students, so that the placement money follows the student and does not get incorporated into core hospital budgets?

    As we continue the transition to the new healthcare education funding system in England, we need to look beyond the immediate implementation of these reforms to the longer term. The retention of staff within the NHS is a far greater challenge than recruiting students to join undergraduate programmes. There is a clear case for the Government to consider “forgivable loans” for students who go on to work in the NHS for, say, three to five years—a cost, of course, but one that could well be outweighed by savings on agency staff and recruiting from overseas.

    For all the debate on pre-registration education, which is entirely appropriate, perhaps a deeper concern for the future lies in an area where very little has been said: that of professional development funding—a silence that we must break if the future of the NHS and its workforce is to be safeguarded through the momentous changes ahead. Central to the implicit covenant we make with NHS staff is that we will support and train them in their jobs. This will become more important than ever as we ask them to deliver the extraordinary challenges that rapid shifts in technology, the genome project, changing patient needs and increased financial pressures demand.

    Yet despite this, NHS England’s centrally distributed budget for ongoing training for more than three-quarters of the health professional workforce has been cut by 45% this year. There is no doubt that the cuts are affecting those professions that are predominantly female. Failing to fund in the areas that we need most in the future, such as return-to-nursing programmes, cognitive behaviour therapy skill development and district nursing, could have serious consequences, and we need to think about care delivery outside the NHS hospital box.

    How can we expect our staff to deliver the NHS five-year forward view and the care our population needs if we do not support their continued professional development necessary to do their jobs? The simple truth is that the national strategic priorities of the NHS, on which there is widespread consensus, and the funding decisions on education and training do not add up. We all understand the financial pressures on the NHS but education and training must no longer be a soft target. We need to ensure strategic leadership so that short-term financial savings do not result in us not having an adequate workforce in the future. I seek assurances from the Minister that the Government will work with and not against the healthcare professions in such a review of looking at how to tackle this subject in the longer term.

    I now turn briefly to one related topic. Since 24 June the need for a senior nurse in the Department of Health as well as a chief nursing officer at NHS England has become even more important. We must have a nurse leader to advise Ministers and others at government level, to represent the UK on the world stage and steer us through the challenges ahead during EU negotiations. Nursing is the backbone of our health and care system. Department of Health-based nurse leadership will make a vital contribution to the challenges that we have to face. One example will be to review the EU professional qualifications directive 2013/55.

    Finally, I recognise that enormous questions need to be addressed following the EU vote. That is why I believe that healthcare professionals should be involved in any discussions affecting our health and social care services. It is only by working together that we will be able to chart a path of success through this new and rapidly changing landscape. The Government must act now to develop a coherent and sustainable workforce strategy for the future, and recognise the essential contribution of overseas staff alongside the pressing need to educate, recruit and retain a workforce from within the UK.

    I look forward to contributions from other noble Lords, who I thank in advance for staying for almost the final debate before the Recess. I hope that the Minister will provide reassurance on the issues raised this afternoon. I beg to move.

  • My Lords, I thank the noble Baroness, Lady Watkins, for securing the debate.

    I draw your Lordships’ attention to a very interesting and concise blog from Miss Clare Marx, the president of the Royal College of Surgeons. She makes three important points. The first, already voiced in many quarters, is that losing non-UK staff would, in her words, be “cataclysmic”. I totally echo the words of the noble Baroness. Toughened migration rules often affect technicians, porters and cleaners. A clear message must be sent to the Government that the NHS needs to retain these vital staff.

    Miss Marx’s second point is the opportunity that will be presented to the NHS to improve patient safety. Up till now, the UK has been required to accept the lowest common denominator of standards across Europe. An example is that some devices have found their way into the UK having been approved in European countries with lower safety standards. In many cases, these standards need to be toughened up, but at the same time the baby must not be thrown out with the bathwater. Care must be taken. The stricter regulations could make it harder to attract international innovators in healthcare. In other words, a sensible mean must be struck.

    Ms Marx’s third point is a vital aspect of the changed climate in which healthcare in the UK will find itself post-Brexit—language testing. This is a subject not infrequently aired in your Lordships’ House. The law as it stood until 2012 was governed by directive 2005/36, which concerned mutual recognition of professional qualifications by all member states. Under this directive, healthcare was lumped in with professions such as engineering, surveying and so forth. It meant that English language testing could be made only following registration by the appropriate body, such as the General Medical Council and the Nursing and Midwifery Council.

    The effect of this, particularly in the case of nurses, was that there were cases where a candidate could obtain registration and disappear, as far as the regulator was concerned, never to be seen again, with, of course, their English language ability untested. There were cases where the only evidence of English proficiency was a certificate obtained for a fee at a street corner in an eastern European capital. Representations were made, particularly from the UK, that healthcare differed from other professions, in that there was the additional consideration of patient safety and that it accordingly required special treatment. Thanks to the persistence of the Department of Health—I particularly mention my noble friend Lord Howe and my honourable friend Dan Poulter in another place, both at that time Ministers in the Department of Health—the Commission accepted the case for language testing of health professionals prior to registration. This can now be required not as a routine, but when the relevant regulator has reasonable grounds to believe that a candidate’s English language skills are not adequate.

    This has been a step in the right direction, but it is not enough. At present the EU, within the constraints I have just mentioned, permits testing only on broad English language skills—effectively, conversational English—while to take the case of the GMC, candidates from outside the EU are required to show English language proficiency in, and I emphasise this, a clinical context. There is a huge difference between these levels. Note-taking is a particularly strong tradition in British medical practice. As one facetious journalist has written, the difference between a microgram and a milligram can be a coffin.

    I urge the Minister to give priority to completing this mission, which is to require that all healthcare professionals coming to this country, from within and without the European Union, are subject to meaningful English medical language tests prior to registration. There is an urgency about this—patient safety is involved—and I hope this can be put in hand straightaway in the time remaining while the UK is still within the European Union, if not in the hopefully constructive environment post-Brexit, freed from any constraints imposed by Brussels.

    The other matter that needs urgent review is the working time directive. Surgeons in particular have had long-standing concerns about the impact of the working time directive on time for training. In 2014 the task force on the EWTD concluded that we need greater flexibility for training hours while ensuring we never go back to a culture of excessive working hours that can only harm patient care. I understand the task force is due to report shortly. We await this with interest.

    Finally, a brief word about research. It is essential that arising out of the Brexit negotiations there is sustained funding and continuing mobility of researchers and clinicians to ensure that the UK research industry can thrive and advance patient care.

    I declare my record as a remainer at the referendum, but, as has been widely quoted, we are all Brexiteers now. I am confident that Brexit will provide a not-to-be-missed opportunity to rectify some of the anomalies and deficiencies in clinical practice that continuing membership of the European Union has involved.

  • My Lords, I congratulate and thank my noble friend Lady Watkins not only on securing this debate but on her excellent speech and setting the scene so ably this afternoon. I also thank the noble Viscount, Lord Bridgeman, for his tenacity of purpose. Ever since I joined the House, he has shown tenacity of purpose in regard to the English language and the statutory bodies.

    I declare an interest as set out in the register. I am a retired registered nurse trying to keep up to date—and that is a job in itself. I will concentrate on the supply and delivery of quality care, not only in the National Health Service but in the private and charitable sectors.

    In preparation for this debate, I gathered together the most recent headlines, which, I am afraid, do not make very happy reading. The Nursing Standard said:

    “The United Kingdom is unprepared for nursing shortages”.

    Health Service Journal stated:

    “Reality bites as the NHS is told to face up to its failings”.

    The BBC reports:

    “Nurse shortage could last for years … 1 in 10 nurse posts in England unfilled … 29% of nurses are aged over 50 … 13% of nurses come from overseas”.

    “Brexit may hit NHS nurse ‘pipeline’”,

    says the chief executive of the NMC. The Nursing Times states:

    “European nurses feel chill after Brexit vote”.

    The Health Foundation report, Staffing Matters; Funding Counts refers to “pressure points” and associate nurses.

    Like my noble friend Lady Watkins, I was filled with joy when I read the report from Simon Stevens. Like her, I had written my speech before I read his report. I will say more on that later.

    I wish to take noble Lords back to the period before May 2010 when the Labour Government were in power and the noble Lord, Lord Darzi, the then Minister of Health, introduced care pathways and was seeking means of ensuring safe, high-quality delivery of care to the satisfaction of patients. Much progress was made on this but with the change of Government, the unmandated Health and Social Care Bill was introduced and proceeded through the next four years before completion. During those four years, I contributed at each stage of the Bill, along with other noble Lords, to establish safe staffing levels and either certification or regulation for support workers.

    Since July 2014, much work has been attempted by various organisations to establish safe staffing levels comprising not just numbers but quality assurance by providing the appropriate level of competence of nurses and support workers. Without that assurance focused on the quality outcome, numbers alone will not take us forward. What we cannot afford is a further spate of inquires relating to unacceptable levels of low-quality care in view of the evidence of the dependency required by the patient, as occurred in the Mid Staffordshire inquiry.

    The report by the noble Lord, Lord Carter, for example, relates to the number of workers and the number of hours per patient day required but gives no indication of the ratio of registered nurses and support workers. There is no regard to the spread. This presents a real dilemma: if the numbers required cannot be afforded as being both the right number with the right quality, then choices have to be made as to the level of service that can be provided, or alternative methods of funding have to be found. But what we cannot afford is further delays with the possibility of poor delivery of care because of the shortage of the right numbers of workers with the right qualifications in place. In short, we require a strategic plan that has explored options on numbers, quality outcomes, cost benefit, risk assessment and a timetable for implementation.

    The regulation of support workers fell to Health Education England to initiate and the noble Lord, Lord Willis, produced the report Raising the Bar, which dealt with nursing associates. Work is now under way to pilot the introduction of the nursing associate and to build on the current support worker grade 2 and 3 to a level 4, extending the role to support the registered nurse, possibly with the academic requirement and aptitude to proceed to registered nurse training or to a degree.

    While I applaud any possible move to develop further support for support workers and agree with the direction of travel, I find it difficult to accept the title “nursing associate”. This may sound pedantic but already there is confusion and many are referring in official documents to the “associate nurse”. The use of the word “nurse” is regulated by law, applying to those who have the required qualification and registration by the NMC. I am concerned that not only other professionals in the health service but—most of all—patients will be confused. To patients, quite rightly, a nurse is a qualified nurse. The fact that the person might not be a nurse at all would not enter their heads. If the title were, for example, “associate health carer”, it would indicate that they were not registered nurses but someone trained under the supervision of a registered nurse. This would help to prevent confusion—which could easily escalate—creeping into the title.

    Evidence clearly shows that the previous state-enrolled nurses were abused and misused; they were exploited through being left in charge of wards with no appropriate support available. The likelihood of this happening must at all costs be eliminated. The advantage of the title “associate health carer” would be that the syllabus could include an introduction into social care aspects of the patient’s journey, which is especially necessary for care in the community, where we have the elderly, the mentally ill and some long-term dependent patients with learning disabilities who are cared for in the community but could be supported towards living a more independent life. This would provide excellent experience for those with the appropriate academic qualification. We need this opportunity for them to be trained and able to move forward, which would, we hope, break down some of the barriers between the organisations and the professions.

    I suggest to the Minister that, while speed is of the essence to sort out the nursing associate, it would be preferable for health education to explore more fully the possible benefits that the role could have, for the benefit of not only the recipients of the care delivered but the nursing associate—or associate health carer—grade. The name is the key and it would be helpful if this could be examined. I look forward to hearing what the Minister has to say on that.

    Safety and high-quality care cannot be ignored; we know the consequences of doing so are dire, as we witnessed in Mid Staffordshire, Winterbourne View and Southern Cross. We have to get rid of this idea of graduate nurses being “too posh to wash”. We urgently need to ensure the graduate nurses, on qualification, are responsible for the delivery of total assessment and care of the patient for whom they are responsible. Each patient is a unique individual who has a mind, body and spirit and it is the nurse who is responsible for assessing and addressing any issues that the patient may have, even if they are not immediately connected to the condition being treated. For example, a terminally ill patient may need to see a priest or the patient may be worried about a dependent relative who needs a social worker. The graduate nurse has the responsibility for the total holistic care of the patients allocated to him or her.

    I also ask the Minister to address the question the noble Baroness, Lady Watkins, asked about the position of the nurse in the Department of Health. We are already in correspondence on this but it is a matter of great concern to the profession.

  • I, too, thank the noble Baroness, Lady Watkins, for initiating this important debate. I declare that I am married to a health trust chairman.

    As if the current pressures on the NHS’s finances and ability to cope were not bad enough, they now have the hammer blow of impending Brexit. Clearly, there needs to be much better workforce planning and support. But at present we absolutely need EU staff and it is as a result of the shortage that the Migration Advisory Committee recently advised the Government to keep nurses on the shortage occupation list. Everyone is calling out for EU workers to get the clarity and reassurance they deserve regarding their future status in the UK. This is particularly vital in key public services such as the NHS to aid workforce planning and ensure that safe staffing levels are maintained. It was reported last November that eight in 10 hospitals missed their target for day and night nurse staffing.

    The Health Secretary himself said on 5 July in the other place:

    “It is fair to say that the NHS would fall over without the incredible work”—[Official Report, Commons, 5/7/16; col. 730.]

    that EU workers do in the NHS. I am not sure I heard that from his lips or those of any other Minister before 23 June. In a similar vein, the chairman of the Tavistock and Portman Foundation Trust, Paul Burstow, said:

    “Without EU care professionals our NHS and social care sector would struggle to function”.

    So we are not talking about a contribution from EU nationals at the margin. It is core. This is one of the many reasons why I am not a Brexiteer now and remain a remainer.

    Some of the facts have been cited. Overall, 5% of NHS staff in England are from EU countries but in London they represent 10% of the NHS workforce. While 10,000 doctors from other EU countries are reported to be working in the NHS across England, the GMC says there are 30,000 EU doctors in this country altogether; perhaps they are working as locums or in private practice or are registered but not practising. There is an interesting extra 20,000 doctors somewhere. There are 6,500 scientific and therapeutic staff across England from other EU countries.

    EU staffing is particularly significant for London and for specialist trusts. The Royal Brompton & Harefield NHS Trust has over 15% of its workforce from other EU countries, while for Great Ormond Street Hospital the figure is 11%. The top 10 all have between 11% and 15 %. But those proportions are for all staff. At Great Ormond Street, a quarter of doctors, 16% of nurses and nearly a quarter of research staff are from the EU. No wonder its chief executive has expressed deep concern about the impact of Brexit. He said that the rare and complex diseases seen in children treated at his hospital required clinical and research collaboration across Europe and, of course, worldwide.

    Last but certainly not least, 6% of the social care workforce in England is from other EU countries—80,000 people in England alone. According to the King’s Fund, there are also regional variations: the figure is 12%, or 20,000 jobs, in London and 10%, or 21,000 jobs, in the rest of the south-east.

    In the light of the catastrophic risk to the NHS from losing EU workers, it is frankly not good enough for the Health Secretary to say, as he did on 5 July in the other place:

    “As long as the UK is subject to EU law, current arrangements remain in place”.—[Official Report, Commons, 5/7/16; col. 728.]

    Yes, they do, but if he expects us and the staff to be reassured by statements by the Foreign Secretary and Home Secretary that the Government want to find a way of allowing those people to stay in the UK for as long as they wish to, we are not reassured at all by this promise of possible jam tomorrow. Staff are very unsettled, trusts report.

    The Health Secretary also acknowledged that the issue of whether or not the £500 health surcharge on non-EU migrants on long-term visas would apply to EU nationals currently living in the UK,

    “would obviously be subject to the negotiations”.—[Official Report, Commons, 5/7/16; col. 729.]

    What kind of clarity, certainty and reassurance is that?

    The NHS Confederation is surely right to insist that immediate steps should be taken to assure staff from other EU countries who are currently working in the NHS and social care that they will be able to remain in the UK indefinitely. I add that this should be on current conditions, including free access to healthcare. The uncertainty created about our ability to recruit from other EU countries in future is also deeply worrying NHS leaders, given current staff shortages. We have an immediate and pressing need for clinical staff, which cannot be met from our domestically trained market. It is a disincentive to EU staff when they do not have certainty on their future residence. The drop in the pound means less purchasing power to send money back to families, which is demotivating as well. It is also predicted to increase the NHS bill by £900 million, as suppliers will have to increase their prices to account for the drop in the pound.

    The message from NHS and staff bodies is a united one: given the length of time taken to train a nurse, and even more a doctor, a failure to offer staff from the EU certainty about their future status risks not only undermining workforce planning in the NHS but the ability of the health service to maintain safe staffing levels and patient safety. If social care struggles to deliver services, the knock-on demand for NHS care will increase still further. Mencap has advised that there are already established and well-known difficulties in recruiting and retaining a sufficient number of doctors, nurses and care staff and that any disincentive or impediment to recruiting staff from EU countries will serve only to stretch these services further.

    This House has on many occasions expressed its worry about the impact of Brexit on all scientific research, both staffing and funding, and that applies not least to the medical and life sciences sector. The BMA says it is concerned that as a result of the ongoing uncertainty, there is a significant risk of a loss of capacity within the UK medical research community. It is also aware of anecdotal evidence that people are turning down job offers because of the lack of security following the referendum.

    Many of us want to hear the Government not only give that certainty which the NHS and others are crying out for but to articulate loud and clear an acknowledgement of the contribution made by highly skilled migrants, including doctors, nurses and researchers, in delivering and sustaining public services and the public good. Incredibly and despicably, there have been xenophobic attacks by patients—the noble Baroness, Lady Watkins, mentioned this—who have taken the referendum result as a green light to attack the NHS staff who care for them. The Government need to send a very clear message condemning such appalling attacks.

    Recruitment through EU or EEA free movement is much less burdensome in bureaucracy than for migrants from non-EU countries, so those Brexiteers who claimed that EU red tape was stifling us were barking up the wrong tree on this topic, as on so many others. The chief executive of the Nursing and Midwifery Council, Jackie Smith, said recently that there would be a major impact on the regulator’s ability to process applications if it were required to apply its current approval procedures for nurses from the rest of the world to those coming from the EU, and that it would create greater costs for her organisation in verifying documentation, securing visas and administering the skills test. The mutual recognition of professional qualifications actually speeds up recruitment and training. Would EU staff in future have to go through the tier 2 process and if there is a salary threshold of £35,000, how are nurses whose average pay is £30,000 to be treated under that system?

    I read the same remarks as the noble Viscount, Lord Bridgeman, quoting the president of the Royal College of Surgeons, Clare Marx. She said that Brexit would help patient safety by toughening language tests, enabling the UK to enforce a higher quality of surgical tools and instruments than EU standards and boosting surgeon training, which she claims is impeded by the working time directive. Does the Minister agree with those comments and know whether the Royal College of Surgeons agrees, as a body, with its president on them? The working time directive and its protections against overwork will of course cease to apply if we leave the EU and the EEA.

    The Government keep telling us that they cannot give guarantees to EU citizens until there are negotiations which also encompass Brits abroad. But they have unilaterally replaced our European Commissioner—appointing a civil servant in place of a politician and relinquishing the key financial services dossier—and they have renounced our presidency of the European Council next year.

    When they want to, the Government are perfectly capable of taking unilateral action outwith any carefully prepared Brexit strategy, so the case against unilateral and unconditional guarantees for EU staff in the NHS and elsewhere gets weaker by the day. I want to hear such unconditional guarantees. As an early win, we need to give a commitment to staff from other EU countries very quickly that they will be afforded indefinite leave to remain, with no new red tape or health surcharge; a message about how valued staff from other EU countries working in health and care are; and a commitment that nurses, and other health-related occupations as and when relevant, will remain on the shortage occupation list.

    I am sure there will be other occasions when we might have to discuss a longer-term approach to migration policy, but in the immediate term we need that certainty and that reassurance. We need guarantees for the EU staff we have currently and those whom trusts are seeking to recruit, as well as similar guarantees on the funding and staffing of medical and scientific research. I hope the Minister will be able to give those.

  • My Lords, I thank my noble friend Lady Watkins of Tavistock for having secured this most important debate and congratulate her on her speech.

    Since the European Union referendum result in England, there have been some most unfortunate incidents of rudeness and abuse to people from other European countries. If these people do not feel wanted and valued, they may not wish to stay and help us. People who have skills to work in our NHS and social care service are desperately needed.

    The Library Note for this debate gives numbers of the various Europeans from different countries, but not of those people who are working in private hospitals or are employed privately helping disabled and elderly people living in their own homes, saving social services millions. The private sector must not be forgotten—it employs many people from overseas. We have an explosion of elderly people, many of whom have complex conditions and need help. Many of the carers themselves are also getting older. With this increasing problem of people needing care, there needs to be replenishment with younger active people as the needs increase.

    Over the years when my husband was ill, we employed many helpers from the EU and other places such as Belarus. Carers for severely disabled people have to be honest, be willing and have a work ethos. Every person with a severe disability has different needs—I declare an interest in that I train my own helpers. I do not think many people who voted to leave the European Union realised that they would be creating so many difficulties and causing so many insecurities in a very unstable world. I think many people thought life would be better, with more money.

    There is a crisis in social services. Unless the Government look at the workforce and realise how we might become isolated from the European Union, there will be a disaster in medical, nursing and social care. I received a letter from a friend of mine, a retired senior nurse from St Thomas’ Hospital, who happened to be in hospital with a complication during the referendum vote. I quote from her letter to me about the morning after: “The day staff came on duty, markedly more subdued than yesterday, and there was a palpable sense of gloom and anxiety—we’ve left”. Among the small group of staff looking after just her little patch of the ward were a Portuguese nurse, an Italian nurse and a Romanian nurse, plus a Lithuanian cleaner, previously a nurse, from Vilnius. Later in the day, she met a Slovenian radiographer and a Polish porter. Without exception, she wrote, their English was excellent.

    It is undoubtedly true that the NHS benefits from the use of already trained staff from the EU and elsewhere abroad, and it will not survive without them. At least one London teaching hospital has recently had to send a recruiting team to Italy because there are insufficient British-trained nurses for its needs. Should these trained and untrained National Health Service staff be asked to leave this country because the UK is about to leave the EU, can they be replaced? There is already a national shortage of nurses and doctors despite our friends from the EU.

    For some time, morale in the NHS has been very poor. It is no good pretending otherwise. Since the referendum vote, there are not only worried staff but very worried patients, especially the most vulnerable. I now declare an interest as president of the Spinal Injuries Association. I ask your Lordships to think for one moment what it would be like to be paralysed from the neck down and dependent on a respirator to breathe. Many such patients who live at home have to rely on trained carers. What will happen if the supply dries up? As it is, it is not easy to get the right people with the correct skills.

    In the UK, there are 750 to 1,000 new paralysed patients a year, about 10 to 15 per million of the population. They have a multisystem physiological impairment and malfunction dynamic. They need specialised care and treatment. In Germany, there are 1,200 special beds for spinal injury patients in special units, while the UK has only 430 spinal beds. The population of both countries is about the same. This means that paralysed patients living in the community often do not get the correct treatment when they need it, as the units are full. Because the work is demanding, these units often have to rely on medical and nursing staff coming from other European countries and beyond.

    The Royal College of Physicians has considered the implications of the EU referendum. It states that doctors from the EU make up a significant proportion of the NHS doctor workforce—about 10%. The UK is already facing significant recruitment problems: 40% of advertised consultant posts remain unfilled. The number of medical trainees has decreased by 2.3% within the past year. This is creating significant implications for the future delivery of care, particularly as the needs of patients increase.

    Care England has told me that one of its larger corporate members was due to go to Portugal this month to recruit care workers, but, further to the result of the referendum, more than 50% of the people in Portugal who had expressed an interest withdrew their names. This period of uncertainty is causing problems. I cannot understand why the Government cut funds to Health Education England, which trains medical and nursing staff. It seems extraordinary.

    I end by saying that it is depressing to see that our results in cancer care are at the bottom end of the European ladder. There is no doubt that working together in research is vital. The UK has been very successful in attracting research funds from Brussels. Losing generous sources of financial support will set research back. Senior researchers are likely to find ways in which to keep direct bilateral collaboration going with colleagues overseas, but the opportunity to take a lead role within EU funding programmes will disappear—very sad.

    Probably the biggest loss will be for the younger generation of science graduates, whose options will be reduced. Biomedical science relies on shared ideas, international co-operation and professional ability. It will take time to find alternative pathways for young scientists. The uncertainty over the specific nature of Britain’s role in Europe could make for a bumpy ride for British science.

    I was very sorry to hear that the department responsible for life sciences has gone, along with the post of the excellent Minister, George Freeman, who did so much to raise morale and interest in this highly important subject. The National Health Service and social services need good morale.

  • My Lords, the NHS is Britain’s national treasure. It is something we are all proud of in this country, something we all benefit from and rely on from cradle to grave—yet it is an institution that is constantly under pressure and which faces enormous challenges. It is the largest employer in the country and the sixth-largest employer in the world. Across the board, with doctors, nurses and administrative staff, the NHS has always relied on huge numbers of foreign staff, from within the EU and from outside it. Today there are nearly 60,000 EU nationals working in the NHS. Jeremy Hunt, the Health Secretary, voiced concerns about the impact of a leave vote, stating that, “Another issue”, alongside the potential impact on NHS investment,

    “is the damage caused by losing some of the 100,000 skilled EU workers who work in our health and social care system. Uncertainties around visas and residency permits could cause some to return home, with an unpredictable impact on hard-pressed frontline services”.

    Simon Stevens, the chief executive of the NHS, said:

    “We’ve got about 130,000 European Union nurses, doctors, care workers in the NHS and in care homes. And we should surely miss the benefit they bring were we to choose to leave”.

    I thank the noble Baroness, Lady Watkins, for initiating this debate. It is widely acknowledged that the NHS is struggling to recruit and retain staff. In 2014, there was a 50,000 shortfall between the number of staff that providers of healthcare services said that they needed and the number of posts, with particular gaps in nursing, midwifery and health workers. Yet the coalition and Conservative Governments set themselves a target to reduce net migration to a level of tens of thousands, which they have completely failed to achieve, with the current level running at 330,000. Just this week, the Foreign Secretary and the Home Secretary distanced themselves from that target, discussing sustainable levels of migration rather than specific targets. The Prime Minister has now been forced to accept that it will take some time to reduce migration to the tens of thousands. Will the Minister confirm that it is still the Government’s policy to reduce net migration to the tens of thousands and clarify when exactly that ambition is likely to be realised—particularly keeping in mind how the Government will achieve that when the NHS and care sector alone employs 130,000 migrants?

    I remind the House of the widespread fear created last year when the Home Office announced that nurses would have to leave the UK if they were not earning £35,000 within six years of living here. I remember how appalled the public were on hearing that. Nursing is one of the noblest professions; nurses work extremely hard, long and unsociable hours, and have always been significantly underpaid for what they do. Many nurses who have come here from the EU and outside would have been forced to leave the country. People who have contributed to our country and who have helped to save lives would have been uprooted from families through a draconian, ruthless and uncaring move. Thankfully, though a public outcry and the nursing professions’ emphasis on the severity of the UK’s nursing shortage, the Government did a U-turn and nursing was added to the shortage occupation list at the end of last year, meaning that nursing was exempt from these rules—thank God.

    The Government’s thinking is what is so worrying here. It has led to ill-thought-out policy decisions previously, with the Government committed to Brexit and with Vote Leave’s campaign focused mainly on reducing migration. We are again in danger of implementing draconian measures that would cause untold damage to our most prized public service. The Government want to reduce migration, but here we have our treasured NHS reliant on that same migration. We are told that it is business as normal until Britain leaves the EU, but it is not. Every day of uncertainty risks skilled EU nationals leaving our country and the NHS. We need to give them reassurances to ensure that does not happen. Will the Minister give us that reassurance?

    Quite apart from Vote Leave’s constant claim that EU migration is putting pressure on our public services, in this case, without EU migration, the NHS, the jewel in our crown, would collapse. People speak about migrants making it more difficult to see their doctor, but more than a third of doctors working in the NHS were born abroad. The whole campaign in the build-up to this wretched referendum was toxic, and much of what people voted on was nothing to do with the European Union. In fact, the King’s Fund said clearly that the tension between staffing levels and the financial pressures felt by care services is nothing to do with the EU.

    A member of my team, who moved to this country 16 years ago and is married to an Englishman, went to the emergency room on the weekend after the EU referendum with a bloody finger which was broken in four places. She was told by somebody sitting next to her in the waiting area that she was a burden on this country. She has worked hard, paid taxes and contributed hugely to this country but was called a burden. That is just one of the many reported sad cases of racism and hate crime that have exploded since the referendum result.

    During the EU referendum, there were many cases in which the NHS was used, as it has been used so many times in history, as a political football. There was the infamous Vote Leave battle bus, which had emblazoned on it:

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

    Then there was the infamous Vote Leave campaign film showing the fate of the NHS inside and outside the EU, ending with the words:

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

    Those were absolute lies. The £350 million was incorrect. We contribute £150 million net a week, which is £8 billion a year, and even if the £8 billion was all spent on the NHS, it is a department with a budget of well over £100 billion. Nobody put the £8 billion into the context that it is 1% of annual government spending. It would not even shift the needle, but the Pied Pipers of Hamelin fooled the British people. I have heard of individuals saying that they voted to leave the EU to save the NHS. That is sickening, gut-wrenching. Does the Minister agree?

    We are meant to be a first-world country. What was the Electoral Commission doing allowing a campaign bus bearing false information to drive around for months and feature as the backdrop of TV interviews day after day? When my business, Cobra Beer, advertises on TV, it is regulated by the Advertising Standards Authority. We cannot make claims that are untrue or misleading as the ASA would make us take down the ads immediately and we would face the possibility of fines and a loss of reputation. However, I am told that in the referendum the ASA had no control. What is going on? Will the Minister explain why he and fellow Ministers stood by and allowed false statements to be made without holding the perpetrators to account? Does he agree that we need elections to be supervised by an Electoral Commission with teeth? In India, which held the largest democratic elections in the world, with 800 million voters, the Chief Election Commissioner is the most powerful person in country at election time. He is more powerful than the Prime Minister.

    The pressures on the NHS and its staffing are because of many other factors that are nothing to do with the EU or migration, such as our ageing population. Even before the EU referendum, the causes of the current nursing shortage were identified: the Government had not funded enough student nursing places; the nursing workforce was ageing; and gaps were not being filled. Since the Francis report, safe staffing levels and increasing healthcare demands on NHS services have pushed up the demand for nurses, while at the same time trusts have faced greater financial difficulties which have made recruiting more difficult.

    After the EU referendum result, Jeremy Hunt told EU workers:

    “You do a brilliant job for your patients, you are a crucial part of our NHS and as a country we value you”.

    Underlying all this is uncertainty surrounding what will happen to EU nationals in the UK while we are negotiating with the EU and whether Parliament will be fully involved in the decision on whether or when to invoke Article 50. Will the Minister tell us that it will go through Parliament and will not be a government decision alone, in the way the Government decided to withdraw from the presidency of the EU in the second half of 2017 without consulting Parliament?

    Hours after the EU referendum result, Nigel Farage stated that the official Vote Leave campaign’s call to spend £350 million a week extra on the NHS with money saved from contributions to the EU was a mistake and could not be guaranteed to happen. What hypocrisy!

    There are further, broader implications of leaving the EU—for example, for companies seeking to conduct clinical trials. The UK will lose influence over the European Medicines Agency. Simon Stevens, the chief executive of the NHS, wrote recently of his blueprint for the NHS to survive life after Brexit, including acting on prevention and health inequalities. He says that how NHS healthcare is provided needs a major overhaul, and that if GP services fail, the NHS fails. He even says that there is no need to “take back control”, in the words of Vote Leave, as:

    “We already make the big decisions about our health system largely as we please, as do the Germans, the French and the rest”.

    He says that the Government need to invest in NHS infrastructure and,

    “as the largest employer in Europe, the NHS needs to do a better job training and looking after our own staff”.

    He says that while the NHS is the cheapest health system in the developed world, there are still major inefficiencies to be tackled, and the time for change is now.

    To conclude, here we have the three Brexiteers that the PM in her wisdom has appointed to take us out of Europe. Their motto must be, “All for one and none for all”. David Davis has said that his target is removing the UK from the EU on 1 January 2019 and pressing the button on Article 50 by 1 January 2017. I say to him, “Dream on”. The PM says, “Brexit means Brexit”. I ask her, “What does ‘Brexit’ mean?”. It is still very much up in the air. This debate is just one example of the drastic impact of Brexit.

    The NHS, the heart of this country and of everyone’s lives in this country, is reliant on EU migrants to keep us alive—and we want, in the words of Vote Leave, to “take back control”? We are losing control day by day.

  • My Lords, I thank the noble Baroness, Lady Watkins, for giving your Lordships’ House an opportunity to consider such an important issue.

    Like the noble Baroness, Lady Masham, I wonder whether noble Lords might consider looking at the issue from a slightly different perspective, that of a patient—in this case a little boy who spent much of his childhood up to the age of 10 in an NHS hospital bed. So frequent were those little boy’s fractures that more often than not he spent either Christmas or his birthday, which happened to be in June, with his broken leg in traction. Some years he even managed to celebrate both his birthday and Christmas in hospital. Often in pain, frightened and tearful, the boy found that the familiarity of the faces of the doctors and nurses on the children’s ward provided real comfort and reassurance. Today it might be called “continuity of care”, but for that little boy it meant everything. I know, because that little boy was me.

    Would the statistics—the 52,000 staff currently working in NHS trusts and clinical commissioning groups who are EU nationals, or 4.95% of the total, 7,297 of them from Poland, 7,121 from Spain, 6,227 from Portugal—have meant anything to my younger self? Probably not. Now, though, such statistics and others mean much more to my older self. For example, as has been mentioned, according to the Royal College of Nursing there are currently 23,000 EU nurses registered to work in the UK. Small wonder that the RCN argues that EU nurses make a vital contribution to the NHS and the health of the nation. What about social care? According to the King’s Fund, an estimated 6% of jobs in the UK social care sector and 12% in London’s are filled by EU migrants.

    Taken together, all these statistics surely point to the fact that as a nation we need to give urgent consideration to how we grant these people the security that they need as soon as possible. My fear, as other noble Lords have expressed, is that otherwise we will not retain their valuable services. I was concerned to read the words of the chief executive of the Voluntary Organisations Disability Group on this issue, who says that,

    “in some services around one quarter of the frontline workforce originate from the EU … If EU staff become anxious and leave there will be an immediate impact on capability and capacity within the sector, which will compound existing workforce shortages”.

    The UK cannot afford for that to happen, not least because, as Simon Stevens, chief executive of NHS England, so eloquently argued in his excellent article in Tuesday’s Daily Telegraph, to which the noble Baroness, Lady Watkins of Tavistock, already referred:

    “If home care disappears and care homes close, A&Es are quickly overwhelmed”.

    Simon Stevens is surely absolutely right to make the further point that,

    “it should be completely uncontroversial to provide early reassurance to international NHS employees about their continued welcome in this country”.

    I therefore draw comfort from the assurance given by my right honourable friend the Secretary of State for Health that EU nationals already working here are a welcome part of the NHS and that as a country we value them. As the editor of the Health Service Journal recently said, it is vital that existing or potential NHS staff with European backgrounds do not decide that the UK is no longer a place for them. Surely such a danger underlines the need for my right honourable friend the Secretary of State for Exiting the European Union to have securing an agreement on the status of EU nationals working in the NHS and social care very high up his to-do list.

    I hope that the Brexit negotiations will be heavily influenced by both principle and pragmatism: the principle of staying true to the democratically expressed majority view of the UK public in the referendum, including as it relates to freedom of movement, and the pragmatism of ensuring that adherence to that principle reflects the generosity of spirit that makes Great Britain great.

    In that vein, on this, the last day of term before we rise for the Summer Recess, I pay humble homage to a great British parliamentarian and a fellow charity campaigner so cruelly taken from us barely a month ago. I speak, of course, of Jo Cox. So much has happened since then to distract our attention. For me, that means only one thing: as her fellow parliamentarians, we must redouble our efforts to keep her precious memory alive through deeds as well as through words. A dedicated public servant, she would, I imagine, have celebrated the dedication of those EU nationals working as public servants in our NHS and social care sector. What a fitting tribute to her it would be for Her Majesty’s Government to make achieving progress in securing their status a top priority in the Brexit negotiations.

  • My Lords, I too congratulate my noble friend on securing this debate, on her excellent overview and on the detailed illustration of nursing that she gave us. As she said, there is trouble ahead. The NHS is very vulnerable, but so too is social care. It is too early to be clear about exactly what will happen, but it is evident that there will be both short-term impacts and some very much longer-term implications. It is about future recruitment, as well as about maintaining the current workforce. As many other noble Lords have said, there need to be strong and constant reassurances for health workers from the EU, and from other countries, from Ministers, chief executives, professional bodies and colleagues.

    It is particularly sad that, as others have said, the referendum result has released suppressed racism and other anti-social attitudes among some parts of the population, and that it seems to have given permission for them to be expressed. These need to be put very firmly back into the box, but the underlying causes also need to be addressed. The Government have particular responsibility to provide clarity in this respect and not to destabilise the situation by questioning the status of immigrants now coming in from the EU. We need careful and considered public statements and policies.

    I am one of the later speakers in this debate, so I shall start from a slightly unusual place by emphasising what is, I think, a potentially positive aspect of the Brexit vote. The UK currently has the most extraordinary strength in health, biomedical sciences and life sciences. Some noble Lords may know that last year the All-Party Parliamentary Group on Global Health, of which I am a co-chair, put together a very large report on this issue, looking at our strengths in four sectors that are all linked: academia, government—by which we mean the work of DfID as well as the NHS—commerce and NGOs. In all those sectors the UK is a real world leader, coming first, second or perhaps third, generally with the US beating us. We argued in that report that we should build the UK as a great health hub or centre for health—rather as we have a great financial centre—for the benefit of the world and the UK.

    We have a great tradition. Over the years we have produced many great global public goods in health. I think of the work on malaria, on the genome, on neglected tropical diseases and on a whole range of areas, some of which have no immediate or direct relevance to us in this country. As a result of all that work, we have the most astonishing range of global partnerships. One sees that particularly in our academic work but also in these other areas. All that is good for UK influence and UK commerce—for the UK’s status and economy.

    Most obviously, Brexit provides an opportunity as the UK seeks to find a new role in the world. It gives extra emphasis and importance to this vision of an outward-focused country and of a world leader in health and related sciences—influential and respected. It is good for our security and prosperity, for trading, influencing and leading, and for spreading a clear set of values. It seems to me that this is a vision that needs to be given greater energy as a result of the vote. That is very positive but there are also enormous risks, of which I shall draw attention to just four.

    First, as has been said by many noble Lords, the NHS is in trouble. The Prime Minister’s vision of working for those struggling and just managing applies very much here. We need to expect the NHS to be there for everyone in the country. The NHS as it stands needs to be given a much higher priority than has been the case. I too applaud the piece by Simon Stevens in the Telegraph and his call for some special treatment for, and indeed infrastructure investment in, the NHS in the future. The NHS needs to be part of the future of our country in the way that it has been in the past.

    The second risk is to staffing, which we have talked about very largely in terms of the NHS and social care. However, it applies also to staff in our research teams—our biomedical lifeblood, if you like. Where is the immigration policy that will allow us to sustain those fantastic research and scientific partnerships around the world?

    Thirdly, there is a risk that has not yet been mentioned: that we must maintain the UK commitment to the World Health Organization’s code of practice for international recruitment. Many noble Lords will recall that we signed up in 2010 to this global code, following on from earlier UK and Commonwealth codes, which essentially said that we should be recruiting people only from countries where there was not a shortage of health workers and, indeed, in some cases, where the Government were keen for us to recruit people. While we have done reasonably well, others around the world have not. However, one can well imagine the pressures coming from this debate leading to us seeking to recruit in ways that are not consistent with that code of practice and perhaps taking us back to where we were before.

    The fourth big risk is to research. We already know anecdotally—I suspect that many noble Lords are aware of the fact—that university researchers applying for EU grants now are being told by their EU collaborators, “Please don’t bother; we don’t actually need you and we certainly don’t need you as the lead partner in this application”. The impact is already being felt in that very important area.

    Although I might want to try to paint a vision of us as a great health leader in the world, we are vulnerable, for all the reasons that we have talked about. Not only is the NHS vulnerable, as my noble friend’s debate is leading us into discussing, but so is our place in the world in this developing field. Health is the biggest industry in the world now and one of the fastest growing, at 5.2% annually.

    The last comments that I made are all very negative and make it difficult to see how we can alleviate these problems. But let me finish with two points. First, what are we doing to become more self-sufficient in health staffing? What are we doing to boost training? We have been, over many years, on a rollercoaster of increasing and reducing training—for example, of nurses, although I do not just mean of nurses. It seems to me that this needs to be given much more priority so that we can approach being self-sufficient. Secondly, the effect of Brexit and the staffing shortages we can already see starting to happen add extra impetus to the need to be innovative, in both service and staffing models.

    I will deal briefly with the latter point, which is about how we deploy and use staff within the NHS and within health and social care more generally. We have heard already about nursing associates—bearing in mind my noble friend Lady Emerton’s strictures, I hope I have got it right when I say nursing associates rather than associate nurses. Another example is one that my noble friend Lady Watkins and I have been working on together in the all-party parliamentary group, looking at the role of nurses. By and large, and not just in the UK but globally, nurses are undervalued and not enabled to operate to their full extent. The extraordinary fact is that we train people up to a certain level and then do not let them operate at that level. There is enormous waste in training people and not using them fully. We will be publishing some proposals about that and hope that the Government will not just listen to those proposals but think even more about how the impact of Brexit is forcing people, or can be used as an impetus, towards greater innovation.

    Although I and others have many questions for the Minister, let me finish with the four that I have highlighted already, if I may—as opposed to the 10 that I had written down. First, will the Government maintain their commitment to the WHO code of practice on international recruitment and report on their performance against it? Secondly, what are they doing to develop the UK’s role as a global hub and centre for health, biomedical sciences and life sciences? Thirdly, what are they doing to increase training and move towards self-sufficiency? Fourthly, what are they doing to develop the role of different groups of health workers, and particularly to enable nurses to fulfil their potential?

  • My Lords, when one gets to this point in the list—and it seems to happen to me quite regularly—most of the statistics have been quoted and the arguments made, but it is worth repeating quite a number of them. I will concentrate particularly on social care, rather than the health service, because that is the area of my expertise.

    The Minister knows that, before we get to the Brexit question, it is quite clear that social care services—and the health service—are in crisis in relation to the demand that is being produced and the number of staff and resources there are to meet that crisis. I am not saying that that is anyone’s fault, but it is a reality that the Government will have to grasp. Looking at the settlement in relation to health, I notice they are beginning to grasp it, but unless we look at the two together, which seems to be being delayed, we will not make a great deal of progress.

    Because it is useful to say something different, I will start with where we are now. If we are going to face the Brexit staffing crisis, we have to be sure that we are doing everything now to make sure that we get staff in post. One tiny example of what we seem to be incapable of doing is that we have to wait 130 days at the moment for the police to clear safeguarding checks. For those 130 days, staff are not in post in care homes or local services—and I speak from experience of this—which means that there is bed-blocking at the other end, because patients cannot be moved out of beds into appropriate facilities. That is a microcosm of a number of issues that I will not go through, but if we are not doing very well at that sort of issue, how much more difficult will it be if we find the worst scenarios in relation to Brexit?

    The Skills for Care national minimum dataset for social care holds information on about 23,000 care-providing establishments and 730,000 adult social care jobs. In 2015, 82% had British nationality, 12% had non-EU nationality and Skills for Care estimates that workers with EU nationality made up 6% of the adult social care workforce—which is about 80,000 jobs, as the noble Baroness, Lady Ludford, quoted. We should hold that number in our minds very clearly. Add to that the 5% of social workers who come from the EU—about 900 in total—which is another area where there are already severe shortages. It is often these staff who are making home and residential assessments as well as being responsible for safeguarding, so that is another area where we will find difficulty.

    Immediately after the Brexit vote, the National Care Forum convened a meeting of a wide range of sector leaders and providers to consider five core issues: workforce; older and disabled people and their carers; funding; costs; and development. But central to their concern was what might be called soft issues. It is essential that the leadership in organisations address the concerns of staff who are becoming extremely anxious—these are people who are employing the staff, so they have direct experience. Staff are already questioning their right to stay. On the other side of the coin, those who are receiving services fear that the services might cease because the staff will have no rights. Will the Minister give leadership and support in ensuring a really clear message about ongoing entitlements and legal rights? We know that we will not leave for two years or more, but unless we reassure people now, two years will be too late.

    At this point, I want to congratulate my noble friend Lady Watkins on securing this debate. Not only that, she has made an extraordinary contribution in her first year and I have learned a great deal from her. Her sheer enthusiasm for the needs of NHS staff and how they should be acknowledged, valued and reassured is something that is very clear.

    If the workforce is to be maintained, the anxiety about the right to stay must be addressed; otherwise, people will not be willing to join the sector, as was indicated by the noble Lord, Lord Crisp. In addition, the fall in the value of the pound may well make working in the UK social care sector less attractive than working in other European countries. There are a number of risks that we have not looked at. Moreover, there is a less obvious financial issue. Many residents in care homes are self-funders. The financial shocks to the stock market may have a significant impact on their pensions and investments, and thus their ability to pay for their care. That is something which we have not really looked at and indeed have not felt the impact yet.

    During the referendum debate, many voices were not heard. Much of the fear of immigration might have been more balanced had information from organisations like the National Care Forum been heard. The kind of statistics that we did not hear about were as follows. In London and the south-east, more than 10% of all jobs are filled by EU workers—and London voted remain. By contrast, only 1% of jobs in the north-east—around 1,000 in total—are filled by EU workers, yet most of the region voted to leave. The disunity in some communities has been widely reported. The Government must take their safeguarding role seriously at this time, when the elderly and disabled who are non-EU citizens become easy prey. Other noble Lords have given examples, and I have heard about a number of incidents where people have attacked the staff who are caring for them. Who, I would ask, do they think is going to care for them in the future if they are so unpleasant to those who are caring for them now? Many already complain about their eligibility for adult social care being removed or reduced for financial reasons, and if staff costs rise due to shortages, there will be an even deeper crisis.

    There are also implications for legal rights, as a significant proportion of the UK’s law comes from the EU, including laws covering the employment rights of the care workforce and the rules and regulations which govern how services are conducted. In theory, the UK Government could repeal some or all of those laws once the exit takes place. Can the Minister confirm that this is unlikely and that EU law will continue to exercise significant influence, recognising that disentangling the UK from its EU commitments will be a lengthy process? These include matters such as rest breaks, statutory leave, compliance with night working limits and the 48-hour working week. Again, theoretically, following Brexit, the Government could change some of the working time legislation. Does the Minister think that this is likely, in view of his party’s search for better conditions, including the living wage for these staff?

    In the worst-case scenario, some 55,000 health workers could face leaving the UK, but, as has been said, there are 88,000 such workers in our care services. Residential homes would cease to function and ongoing home care would be at an even higher premium. As I said earlier, discharges from hospital and community care are inextricably linked, so hospitals would be full of the elderly and disabled in entirely inappropriate care. Those who have fuelled some of the racial tension by saying that EU nationals are taking British jobs should remember that active recruitment has taken place over the years because vacancies could not be filled from the pool of existing UK citizens.

    Sorry, I apologise for my cough. I did see the doctor this morning—he was a very nice Indian.

    The charity Livability, which provides services for disabled people and for which I serve as a senior vice-president, currently has 50 vacancies. That is one medium-sized provider.

    Nor is the Australian system the answer. Basic health and social care workers often start their careers in low-paid caring jobs and gain qualifications and promotion along the way. Can the Minister say where this pool of workers will come from, and will the demographic crisis we face be matched by an even bigger crisis in care? In my view, Brexit was bad news for most of us, but it could be fatal for those in need unless we deal with the issues of confidence and employment at speed.

  • My Lords, it is even later in the debate so I have been crossing out more and more of what I was going to say, which is probably good. I start by declaring my interests as registered, and in particular my heading up of the International Longevity Centre-UK and the fact that I am co-president of the International Longevity Centre Global Alliance.

    The noble Baroness, Lady Watkins, has introduced an extremely timely debate, obviously, and she has emphasised the importance of ensuring safe staffing levels. I think that the word “safe” is very important, both in the NHS and social care sectors. For that to happen, we need NICE to produce indicators to ensure that those safe levels are guaranteed, as Francis recommended back in 2013. I very much hope that that will happen.

    We obviously cannot afford to lose the 5% EU staff who are currently working in both the health and social care sectors in the UK. As the noble Baroness, Lady Howarth, said, Skills for Care calculates that the vacancy rate in the social care sector stands at 5.1%, which is significantly higher than the UK’s labour force as a whole, and up from 4.8% just last year in 2015. That sector also faces ever-increasing demand, as the number of people aged over 80, the most vulnerable group, is expected to double in size to more than 5 million people by 2037, which is not actually very far away. That number is significant.

    Social care providers also find it very difficult to retain staff, as has been said. The International Longevity Centre calculates that the sector experiences a staff turnover rate of 24.3%, which is quite shocking. So the contribution of the 77,000 social care workers from other countries in Europe is absolutely invaluable. The safety and well-being of our population is undoubtedly at risk because of that.

    Indeed, the ILC estimates that there are between 30,000 and 35,000 European-born social care workers across London and the south-east alone, providing a vital public service to our rapidly ageing society. Social care workers born in Europe, working in England today, are also younger on average than social workers born in the UK, with around one in three aged between 25 and 34. They represent a huge source and a huge potential, and they need to be fostered and trained to address the skills shortages across the adult social care sector.

    The NHS Confederation also calculates that a total of 57,604 NHS staff in England alone—I love the precision of that number—come from other EU countries. As 19,000 of these people work in London, both 10% of London’s NHS workforce and 10% of London’s social care workforce were born in other European countries. So it is crucial that the Government reassure the 77,000 social care workers and the 57,604 NHS staff born in other countries of Europe, working here now, that they are free to continue to care and to provide some certainty to a sector which is in a situation of crisis.

    Also, in case EU citizens are ever required to meet the demands of the Migration Advisory Committee’s shortage occupation list, I urge the Minister and the Government as a whole to consider placing senior care workers in the tier 2 category and to open tier 3 for all other care workers to ensure the social care sector has the staff and skills to care for our ageing population.

    Very briefly, demand for this type of care is growing as the number of older people and people with long-term conditions more broadly—with learning disabilities and mental health conditions—increases. It is estimated that at least 1.7 million more adults will require social care over the next 15 years. This could require an increase in its workforce to between 2.1 million and 3.1 million by 2025.

    Some 47% of the NHS workforce is aged over 45, compared with an average of 40% for the English working population. Only 5% of the NHS workforce is under 25. Some 1.2 million people aged 65 and over are in work in England. Perhaps more should be brought into the care workforce. That is another thought: we could bring in some of those older people. I know of a very big American home care company that makes a point of employing older people because they are very good at providing that type of care.

    Let us look just for a moment at what the Royal College of Surgeons has said: doctors from the EU make up about 10% of the NHS doctor workforce. We already face significant recruitment problems because 40% of advertised consultant posts remain unfilled. We know that the number of medical trainees has decreased by 2.3%, just in the last year.

    In numbers, 21,000 nurses across England come from other EU countries, more than half of them work in London and the NHS has this huge shortage of nurses. We have to keep nurses on the shortage occupation list. One of the Health Select Committee’s key recommendations in its report this month is that the Government should urgently assess and set out publicly,

    “the additional costs to the NHS as a result of delayed transfers of care, and the wider costs … associated with pressures on adult social care budgets more generally”.

    Our ageing population presents us with huge challenges—it is good, but it is very challenging—as does the result of the referendum, which we have been talking about. These must be faced and we must overcome them if our common humanity and the values we hold dear in this country are to be safely retained. I hope the Minister will reassure us that the Government will act appropriately to avoid a tragedy that will affect the most vulnerable people in our society.

  • My Lords, I too thank the noble Baroness, Lady Watkins, for securing this very important debate. Indeed, I cannot think of a more pressing and urgent subject on which to finish our sitting.

    As we have heard in the debate, the UK’s vote to leave the EU will without doubt have major implications for health and social care, not least because it has ushered in a period of major economic and political uncertainty at a time when the health and care system faces huge operational and financial pressures, as we have debated so many times in this Chamber. The NHS faces an extremely challenging set of circumstances. Demand, particularly from our ageing population, continues to grow faster than funding, putting further pressure on an already strained service. Fundamental change in how we provide care is urgently needed if the NHS is to be successful in meeting the twin challenges of providing high-quality services while balancing the books. To do this it is vital that we have the right numbers of staff with the right skills in the right place, and ensure that they feel valued, welcome and engaged in the work that they do—hence the debate we are having this afternoon.

    The EU’s policy of freedom of movement coupled with mutual recognition of professional qualifications within the EU means that many health and social care professionals working in the UK come from other EU countries. I know we have already heard these figures but it is important to emphasise that these are big numbers. This is not something at the margins: it is 55,000 of the NHS’s 1.3 million workforce and some 80,000 of the 1.3 million workers in adult social care.

    As we have heard this afternoon, the NHS is struggling to recruit and retain permanent staff. Indeed, there was a shortfall of some 6% in 2014 between the number of staff that providers of healthcare services said they needed and the number in post, with particular gaps in nursing, midwifery and health workers. As we heard very powerfully from the noble Baroness, Lady Howarth, similar problems exist in the social care sector. I will not repeat those numbers but I am particularly worried about the very high vacancy and turnover rates in domiciliary care services, which provide care to some of the most vulnerable people—the elderly and the disabled—in their homes. Given the current shortfalls in both health and social care that we have heard about, surely the Government must urgently clarify their intentions on the ability of EU nationals to work in health and social care roles in the UK, not least to avoid EU staff in the NHS deciding to leave to work in other countries where they may feel that they are made more welcome.

    Initially in the days after the referendum, it sometimes felt as if all EU nationals were being used as pawns in a negotiating game, and that was quite wrong. Since then, we have heard slightly more reassuring statements from Bruce Keogh, NHS England’s medical director, and Jeremy Hunt, the Secretary of State, who has sought to assure European staff working in the health service. We have also heard Simon Stevens call for more assurances, which are needed, and that is the right thing to do. However, we need to go a lot further. Providers of NHS and social care services must be able to retain the ability to recruit staff from the EU when there are not enough resident workers to fill vacancies. As others have suggested, this could be done by adding specific occupations to the Migration Advisory Committee’s shortage occupation list, which currently enables employers to recruit nurses and midwives from outside the European Economic Area. What steps will the Government take on this front?

    I want to say a brief word about nursing staff. I am very conscious that I do not have anything like the expertise that we are so lucky to have in this Chamber in the noble Baroness, Lady Watkins, and, of course, the noble Baroness, Lady Emerton. However, I acknowledge the huge contribution that EU nurses make to the vital work of the NHS and, indeed, the health of the nation. Currently, some 33,000 EU nurses are registered to work in the UK. There has been a very large rise in this number since 2010. These numbers show that the UK has an ever-increasing reliance on nurses from the EU, who plug serious gaps in the nursing workforce. This is due to government cuts since 2010 to nurse education commissioning in the UK, which has drastically reduced the supply of nurses coming into the system. There will be serious consequences for patient care if EU health professionals are forced to leave the country or, indeed, are made to feel unwelcome and so decide to leave.

    It is often the personal anecdote that brings this situation home. Yesterday, I had a very long day—about 15 hours—with my mother in a central London hospital. She is very elderly and frail and she needed an operation. But during that long day all her other complicated care needs had to be dealt with. The nurses in the hospital clearly came from all over the world. I cannot thank them enough for the care they gave my mother during that long and difficult day. It is absolutely clear to me that the NHS simply would not be able to function without staff from other countries; we just have not invested enough to grow our own. It takes four years to commission extra places and train nurses; it is not something that you can do overnight.

    Where does all this leave us? I have to be honest and say that it leaves me feeling quite gloomy. I recently read a very good article in the Guardian, written by Richard Vize. He said that:

    “The most insidious effect of the current anti-European climate will be to discourage EU talent from working in our health and care system”.

    He went to say—and I think that this is the critical point—

    “It is not just a question of the rules about who can work here, but the perception. With social and mainstream media in Europe already reporting incidents of racial abuse and a more general anti-immigrant feeling, and uncertainty about the future legal position of living and working in the UK, talented people from other EU nations have good reason to consider alternatives. There is a chronic global shortage of clinical staff, so the UK is part of a worldwide marketplace for talent. We have just made it more difficult to attract the best”.

    It gives me no pleasure to say so but, frankly, I could not agree more.

    I usually like to end on a fairly upbeat or positive note, as I know the noble Lord, Lord Crisp, does. He managed to do so extremely well, as always, but on this occasion I have failed. I end by raising an issue that the noble Lord, Lord Bilimoria, also mentioned. It is about that lie—that most flagrant and disgraceful lie—of the leave campaign. I have to say that there was very stiff competition for that particular accolade, but it is the lie where we were told that £350 million extra per week would be available for the NHS—it was plastered all over the campaign buses. Then of course it was retracted, even before the ink was dry on the results. But the public, quite understandably, now have an expectation that NHS spending will rise after the UK leaves the EU. I have never been very good at maths but I just made a little calculation. It is four weeks now—to the day, I think—since the referendum, so my calculation tells me that, four weeks on, £1.4 billion is now owed to the NHS. Can the Minister tell us whether that money has yet been received and, if not, how quickly he expects that money to be in the Department of Health coffers?

  • My Lords, we all look forward to hearing the answer of the noble Lord, Lord Prior, to that question. I, too, thank the noble Baroness, Lady Watkins, for an excellent speech and introduction to this crucial debate. The noble Lord, Lord Shinkwin, also made a very moving speech and it was very good to hear his contribution.

    There is obviously a lot of concern about the impact of Brexit on NHS staffing but we have a crisis today. We cannot fill posts. The Department of Health has, in my view, tried to deal with the issue of agency costs but it has not gone upstream to deal with the real issue, which is that we are not actually training enough doctors, nurses, care workers and other staff and we are certainly not retaining them. The antics of the current Secretary of State in relation to the junior doctors, and the impact that this has had on the medical profession, threatens to ensure that we have even fewer staff in the future. It is also becoming clearly apparent from the posturing of the various regulatory agencies and NHS England that the emphasis on safety and staffing since the Francis inquiry has gone and that the pressure on the NHS is on money. We have a double whammy of a shortage of staffing and pressure, undoubtedly from the centre, for staffing ratios to be reduced, not increased.

    The noble Baroness, Lady Tyler, is right; clearly this £350 million is a fantasy—but the Government’s approach to NHS funding is a fantasy. They were exposed yesterday by the Health Select Committee. They claimed £8 billion but then it went up to £10 billion because they added an extra year. As the Health Select Committee has shown, over half of that has been retained by the department because it nicked other budget heads. The actual money is pathetic. It is a less than 1% real-terms increase. The health service has never had such a parsimonious amount over such a long time. The regulators and NHS England have this fantasy that somehow the NHS can provide better services on less money. We are facing a crisis. The care sector, as the noble Baronesses, Lady Howarth and Lady Tyler, said, is even worse. The Brexit decision comes on top of a very serious situation for our health and care system.

    Before I come on to Brexit, in relation to the point made by the noble Baroness, Lady Emerton, about nursing associates, it would be helpful if Health Education England agreed to come and speak to noble Lords on this issue. I am worried that it is making a decision that properly ought to be made by Parliament in creating essentially a second-tier professional nursing grade. It may be right, it may be wrong, but it should not do it itself. This needs to be shared through a parliamentary process.

    I also very much agree with the noble Baroness, Lady Watkins, that the Department of Health needs a lot of advice from professional advisory people. The decision to do away with the nursing, midwifery and allied health professions policy unit has been a very big mistake and I hope it will now be put into reverse.

    The noble Lord, Lord Bilimoria, asked the Minister a series of questions which, again, we look forward to hearing the answers to. The question I want to ask is: what preparation did his department make for the result being in favour of Brexit? I suspect the answer is none. This morning the Foreign Affairs Select Committee of the other place said:

    “The previous Government’s considered view not to instruct key Departments including the FCO to plan for the possibility that the electorate would vote to leave the EU amounted to gross negligence”.

    Anyone who has read the Chilcot report, or the summary, will know that one of its key points was that the then Government refused to let the military plan for the intervention, and the consequences were very serious indeed. When we had the Statement on Chilcot, we were told that the lessons were going to be learned, but this Government went through exactly the same process. On the day after the referendum it was clear that neither the people leading the leave campaign nor the Government had a clue what to do. In fact, were it not for the much-maligned Governor of the Bank of England, I hate to think what would have happened on that day.

    My main question for the Minister is: what work is now being undertaken by the department? Obviously, the fundamental issue is the trade-off between free movement of labour and open access to the EU market, as well as the need to protect workers’ rights. But what about the important issues in relation to health? Is the department now going through a process of working through the issues where we need to reach a decision? What needs to be negotiated and what will be the advantages of coming out of EU legislation? Will the department be consulting with the public and with Parliament on that matter?

    Other issues go more widely than staffing. The noble Lord, Lord Crisp, raised the question of our participation in EU-wide research projects. Is an emergency task force being established to try to get this right so it is accepted that British universities should be part of collaboration in the future, or are we going to go into a three- or four-year downturn in research, which would devastate our universities?

    The second is the life sciences sector, which is a huge asset to this country. What are we doing to ensure that that sector will be able to contribute to our economy and that the innovation it introduces will be enhanced in the future? The failure of the NHS to invest in innovation is one of the most depressing sights that I have seen in the last few years. If we are to enhance the life sciences and pharmaceutical sectors—I am proud of the research-based pharmaceutical sector and I applaud people who work in it; they have contributed a huge amount to this country—we have no chance of retaining R&D in the pharmaceutical sector unless the NHS starts to adopt innovative new medicines. The problem is that a huge amount of rationing is taking place. My concern is that the pharmaceutical industry, and the life sciences sector as a whole, will conclude that the combination of Brexit and the failure of the NHS to invest will lead to a deinvestment. We have to try to sort this through in the next few months.

    My final point before I come on to staffing is on the position of the MHRA and clinical trials. I founded the MHRA, in the sense of naming it from its old form, and I am very proud of its work. But its situation is at huge risk unless we can reach an agreement that the relationship it has with the European agency will continue in future. Will that be the Government’s intention? Clinical trials is another area, however.

    As far as staffing is concerned, I do not have time to raise many issues but, first, the big ask is for a commitment that staff from other EU countries who work in the NHS and social care will be afforded indefinite leave to remain in the UK. Secondly, will the NHS be instructed to take action against members of the public who abuse staff in the way that we have heard about? We need action; it is no good just tut-tutting. I would like to see whether it is possible to prosecute people. I suspect that it is in certain cases but we have to be very tough on patients. If they expect to be treated in our hospitals, then we can expect our staff to be entitled to respect from them.

    The GMC produced a very interesting and detailed note on the impact on the medical profession. Will the Minister assure me that the Government are in discussions with the GMC and the other bodies that are concerned about staffing levels?

    Finally, there is a big question. Because the Government have decided that immigration controls are more important than anything else, should we lose a lot of mutual recognition and full access to the free market then one implication is that we will have to train—and retain—more of our own health service staff in future. Is the Minister’s department working on a strategy to do that?

  • My Lords, this has been a very helpful debate for me. It has been interesting and insightful, and provocative at times, and has also brought to my attention issues that I had not taken on board before.

    I thank the noble Baroness, Lady Watkins, for tabling this debate. It has come earlier than I might have liked, because I have not had a chance to think about all the issues raised, but that is no bad thing. Maybe we should have a similar debate in three or four months’ time, once the Government have had more of a chance to react to the Brexit decision. I also thank the noble Baronesses, Lady Watkins and Lady Emerton, for all the work that they do to promote the great cause of British nursing. It is a very important issue and I think that the work they do is appreciated by everyone in the House.

    I will make a couple of introductory comments. First, I will just put something on record, which I think everyone in the House will agree with, to recognise the fantastic job that is done by EU nationals and nationals from around the world. The NHS could not survive in its current form without the extraordinary contributions that they make. The second thing is to agree with the words of the noble Lord, Lord Hunt, and other noble Lords in condemning any racist or hate behaviour. It is totally unacceptable, and people who do it should be exposed to the full force of the law. I also say to my noble friend Lord Shinkwin how moved I was by his personal story, which brings home to everyone that nursing and medicine is a noble profession.

    There has been a lot of doom and gloom—there have been points in this debate when I felt like slitting my wrists, to be honest with your Lordships. There is of course a lot of uncertainty at the moment, which is a worry to many people, but we should just remind ourselves, as the noble Lord, Lord Crisp, mentioned, that we have some of the finest medical research and life sciences research in the world and punch well above our weight. Just in London, we have UCL, Imperial and King’s. We have Oxford, Cambridge and Manchester—we have some extraordinary research going on. We have some of the finest medical education, and some of the oldest and best medical schools in the world in England, Scotland and Northern Ireland. Many people still regard the NHS as having some of the best standards in the world. The comprehensive nature of our offering to people is still hugely admired around the world. We have some of the most efficient hospitals and the best primary care in the world. Of course there are some serious risks and issues, but let us not forget the extraordinary institution that the NHS is.

    I turn to the Motion before us. Healthcare employment is a hugely dynamic area. We are focused today on the implications of Brexit, but the pressures and dynamics that come into play with our healthcare workforce are huge. For example, there is the changing role of technology and the growth of self-care enabled by telemedicine and other apps that we now have. There are demographic changes and the new models of care that are being developed. There is the impact of pay policy, for example the cap on the public sector. There is the huge underlying impact of our economy. There is the need to move more care out of acute or hospital settings. These are all having a big impact on workforce planning.

    Brexit is one factor—it is an important factor but by no means the only one. It has a huge impact in two respects. First, in that it has an impact on our economy, it will have a huge impact on how we provide healthcare in this country. Any tax-funded system such as the NHS is going to be hugely impacted by the size of our overall economy, but there is not much point in debating that today—you can argue whether there will be a short-term or long-term impact from Brexit, or whether it is going to be positive in the long run, but these are all issues that will have to be decided in the future. The big impact will be on workforce mobility. For all kinds of historical and current reasons, we have a very high number of people from other countries working in our system, which I will turn to later.

    I will start with safe staffing, which was referred to by a number of noble Lords and is a key part of the Motion before us. Responsibility for safe staffing rests with hospital boards: there should not be any one-size-fits-all staffing level. Trusts should have arrangements in place to ensure they have the right numbers and skill mix of staff needed to deliver quality care, patient safety and efficiency, taking into account factors such as acuity and case mix, ward layout and the like.

    On 6 July, the National Quality Board published refreshed guidance on safe staffing. It has been drafted with members of the board, which includes NICE and the CQC, and has been independently reviewed and approved by Sir Robert Francis. It is worth noting that when Robert Francis wrote his report on Mid Staffs—I am probably one of the few Members here who have read the entirety of that report—he specifically did not recommend fixed staffing levels. He was very clear about that.

    The guidance reminds the NHS that in making decisions about safe staffing, trusts should focus on outcomes rather than inputs and make use of a range of resources and metrics, including the care hours per patient day metric, to measure and deploy staffing resources most effectively. I will quote just a short part of the report because it is important, and because it stresses professional judgment. It states:

    “Professional judgement and knowledge are used to inform the skill mix of staff. They are also used at all levels to inform real-time decisions about staffing taken to reflect changes in case mix, acuity/dependency and activity”.

    That is important. You cannot rely on just formulae and algorithms—this is true throughout medical care—you have also to rely on professional judgment. When a new patient comes into a ward who may be likely to fall or who suffers from psychosis of one kind or another, you will have to change your staffing mix. There is a danger in laying down staffing ratios: everyone then works to the minimum, gaming starts and you start counting certain people in the mix but not others. The importance of the new advice is that we must rely on the professional judgment of ward sisters and the like.

    I turn to the impact of Brexit. Until exit negotiations are concluded, the UK remains a full member of the European Union and all the rights and obligations of EU membership continue to apply. The working time directive and directives on speaking English, to which the noble Viscount, Lord Bridgeman, and others referred, still apply. But when we leave the European Union, depending on the outcome of the negotiations, it will be for us to decide whether we want to keep the working time directive, for example, and whether or not we want to change it to make it more in line with the recommendations of the Royal College of Surgeons. That decision will be ours to take at the time.

    The Government’s position is clear. We agree with Simon Stevens that it should not be controversial to provide early reassurance to NHS employees from the EU that they continue to be welcome in this country. This is something we have done already. The Prime Minister has been clear that she wants to secure the status of UK nationals abroad as well as EU nationals already living here. Indeed, in his final PMQs, the previous Prime Minister also made that absolutely clear.

    We are about to begin these negotiations and it would be wrong to set out unilateral positions in advance, but be in no doubt: we recognise that all NHS staff from overseas make a huge contribution to our country. We have had lots of figures today and I think you are all sick of them, but currently, there are estimated to be 53,000 workers from EU member states in the NHS and 80,000 in the social care system. The proportion of overseas and EU staff is much higher in some parts of the country, especially London. Great Ormond Street was mentioned as an example. There are some London hospitals, in particular, where there is a very high proportion of EU staff.

    It is very important that the staff are not unnecessarily concerned about their future. A message of reassurance to all NHS staff has already been sent by Bruce Keogh and Jeremy Hunt emphasising the vital role played by EU nationals working in our health and social care system. This is as true for non-clinical staff and those working in social care as it is for the 10% of NHS doctors and 4% of nurses who are from the EU. It will be a key priority in our negotiations to seek to ensure that those dedicated staff are able to continue making their outstanding contribution.

    We are top of the OECD table in the number of people working in our health and social care system who come from overseas. In part, this is a legacy of empire and the English language and, now, because of our membership of the EU. One in three doctors and one in eight nurses were trained overseas. In a sense, for an employer it is a quick fix to employ a lot of people from overseas; it saves us the cost of training and you can get them straightaway. But I just do not think that it can be desirable that we should depend to that extent on people trained overseas. It did not just apply to those from low-income countries. The noble Lord, Lord Crisp, talked about the WHO commitment that we made to reduce our dependence on those people; it is outrageous to bring people in from low-income countries. It may be different in some parts of the world where they produce deliberately more than they need—in the Philippines, for example. But as a general rule, to import doctors and nurses from low-income countries is ethically completely wrong.

    It is a risk that with Brexit we will, in the short term at least, find that there are fewer people from the EU whom we can recruit, but this is a huge opportunity to train our own people—to train more people in this country to be doctors and nurses. This is one of the great humanitarian professions. In 2002, 50% of all new nursing posts were made up from people coming from overseas. It peaked at 50% in 2002 and came progressively down to about 10% in 2008, but since the Mid Staffs report it has climbed again to a point where it is 30%. It strikes me that that is too high, and that we must do more to increase the supply of nurses and doctors, and to retain them, ourselves.

    So what have we done to boost the supply of domestically trained staff? We have already increased the number of key professional groups being trained. For example, the number of nurse training places being commissioned each year has increased by 15% since 2013, and we are committed to ensuring 5,000 more doctors working in general practice by 2020. The reforms to the funding of training for nurses and allied health professionals will further boost supply by removing restrictions on the number of training places and will result in 10,000 more nurses being able to enter the workforce by 2020. Health Education England estimates that in total 40,000 more nurses will be available by 2020. I accept that, as the noble Baroness, Lady Watkins, said, there is a risk that removing the bursaries and going to a loans system might deter some nurses—but all the evidence suggests that that is not the case and that, on the contrary, many thousands of young men and women, as well as older men and women, who wish to become nurses, are unable to be trained because of the cap on nursing because of the bursary system. So there is strong evidence to suggest that moving to loans will increase the availability of nurses and AHPs.

    Following the Carter review, we are also looking to increase the efficiency with which we use our existing staff and improve productivity, by changing skill mix through the introduction of new roles. This will ensure that highly trained professional staff are properly supported and able to use their skills to do things only they can do. We have talked about the new nursing associate role, and I am very happy to meet the noble Baronesses, Lady Watkins and Lady Emerton, with Health Education England, to discuss that role in more detail, if they would like to do so—perhaps after the summer. If they would like to have a meeting with HEE, I am very happy to arrange that. We are also introducing the role of physician associate, which is a postgraduate qualification; following an undergraduate degree in science, say, there are 90 weeks of training to become a physician associate. That, again, will improve our skill mix.

    The Government’s expanded apprenticeship programme will help NHS employers to recruit staff and reduce reliance on expensive agencies. Through the programme, the NHS is developing a clear progression route for healthcare support workers to become qualified healthcare professionals. This will allow trusts to develop their healthcare support workforce and provide individuals an opportunity to earn and learn. We are investing in new technology across the health and social care system to improve productivity for our staff. I give one example only, because time is running out. Most trusts now have new rostering systems, which enables us to ensure that the workforce is spread more evenly across the day, so that we do not have peaks and troughs when in some parts of the day we are understaffed and in others we are overstaffed. There is a lot we can do to improve the productivity of the workforce we already have.

    I should turn to social care because it is a hugely important area. We have so often done a disservice to social care. People who work in social care do incredibly important jobs. I am sure other noble Lords have visited nursing homes, care homes and care homes for dementia. People who work in those jobs, often on minimum wage, do an extraordinary job. Somehow working in nursing homes and residential homes does not have the status that it ought to have. It is a vital service for many older and disabled people and provides support to the most vulnerable people in our society. The latest figures estimate that people with EU nationality make up 6% of the 1.3 million adult social care workforce, which is about 80,000 jobs. EU workers are highly represented in regulated professions in this sector—nurses, OTs and social workers—and account for around 9% of those jobs.

    Social care is a sector of opportunity with vacancies for the right people. We have to change the status of people who work in social care so that we can attract more people from this country into that profession. What are we doing? The Cavendish review brought in the care certificate, so we are trying to improve the training of people in this area. We are trying to integrate social care much more with healthcare. The Airedale care home vanguard programme is a good example of that. The national living wage is important in rewarding people who work in this important sector, who are often on very low earnings.

    I want to conclude more generally. The noble Baroness, Lady Greengross, said that the turnover rate in social care was 24.3%, which is a huge figure. If we do not treat people properly, get them engaged in what they are doing and trust them, we will have high levels of disengagement, absenteeism, sickness and staff turnover. I do not know so much about social care, but I do not think that in the NHS we do a great job in engaging our workforce although of course some hospitals are exceptions to that. For example, the workforce race equality standard shows very high levels of bullying of people from BME backgrounds. Actually, there are very high levels of bullying of people from all backgrounds in the NHS. This is not because I am pro-private sector or anti-public sector or anything like that, but some of our best private sector companies treat their workforce with a far higher degree of trust and dignity and give them much more support and more training opportunities than we sometimes do in the NHS. In terms of retaining the staff we have, having trained them, there is a great deal that we can do. We can do that job much better.

    My time is running out so, as summer beckons, we should retire, perhaps with a glass of Cobra Beer, and enjoy it.

  • I thank the Minister for his response and his recognition that some of these issues need to be returned to in future as a strategy develops in relation to the Brexit discussions. This country has always worked with staff from across the world, as I was reminded this morning when I went to the Nightingale Museum and saw the wonderful new Mary Seacole memorial. She was a Jamaican nurse who worked with Florence Nightingale. We must not take as long as we have taken to recognise her to reassure EU staff working with us, otherwise they will leave very quickly and, more importantly, new people will not come from the EU to work with us because of the uncertainty.

    I recognise the need to negotiate about UK nationals who live in other EU countries. However, a swift assurance to all EU health and care workers in the UK would serve to reassure not only them but the vast majority of EU nationals who actually live in the four countries of Great Britain. I therefore urge that we do not take too long to reassure everyone about the need to continue to have this mixed workforce, to get a proper continuing strategy for health and education in future, and to ensure that we not only train new nurses and doctors but give them continued professional development so that they want to stay in this country and become a core part of our retained senior workforce.

  • Motion agreed.