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NHS: Staff Numbers after Covid-19

Volume 810: debated on Thursday 4 March 2021

Question for Short Debate

Asked by

To ask Her Majesty’s Government what plans they have for the number of National Health Service staff after the COVID-19 pandemic.

My Lords, I count myself very fortunate to be introducing this Question. This is an invaluable parliamentary means whereby questions can be asked in a more discursive manner than usual and the Minister will listen and, we hope, provide answers. I shall make a couple of obvious general points.

The people of Britain love the NHS, as has been seen during the Covid-19 pandemic, but there were problems prior to the pandemic. I shall make three basic points to set the scene. The NHS is the fifth-largest employer in the world, yet we spend less on health as a percentage of our GDP than almost every other developed country in the world. To compound the situation domestically, there was a shortage of hospital beds prior to the pandemic. Indeed, we are bottom of the Euro league for intensive care beds, with 7.3 beds per 100,000 of population, compared with the best, Germany, with 33.8 beds—what a difference. Thus, prior to the previous cuts we were ill-prepared, and there have been too many cuts under the austerity measures of the early 21st century.

I am certain in my own mind that it was due only to the dedication, brilliance and sacrifice of NHS staff that we got through—and I mean all staff, from the top consultant to the most junior worker. And it has been at tremendous cost to many of them in stress, burnout and mental health challenges. We owe them a tremendous amount and I hope that, in his summing up, the Minister will confirm that this will be recognised when we have won the battle with Covid-19.

I will begin with nurses. Over the years, the Minister must have become tired of me pursuing him on the issue of nurses. I remain concerned. Currently, we are at least 40,000 nurses short. Over the next seven years we will face a shortfall of 108,000 nurses. I must ask the Minister very bluntly: will HMG drastically increase the training of fully qualified nurses? What discussions has he had to ensure the provision of the educational means to do so?

The Royal College of Nursing has conducted surveys and expressed deep concern about the exodus of qualified staff following the pandemic. I share that concern. Will the Minister push ahead and prepare plans to deliver what is necessary to persuade staff that they are valued, and to retain them in the NHS? According to the RCN survey, 35% of nurses are contemplating leaving the profession within the year. Will HMG also provide the NHS with the means to fund occupational health and psychological support, and, if necessary, breaks beyond annual leave?

Nurses are due a pay rise. They are currently worse off than they were a decade ago. Will HMG ensure that the upcoming pay settlement is really meaningful and commensurate with the ever-rising skills of nurses?

I turn now to GPs. If we are to meet the demands and expectations of the general public, we will have to increase the number of doctors, especially GPs. Does the Minister accept that we are still suffering in the training of doctors from the austerity years, over which his party presided? In spite of the modest increases of late to close the gap, does he accept that we face a shortfall of 7,000 GPs in the next two years? As a starter, we need to double the number of medical school places from 7,500 to 15,000 by the end of the decade.

I will move on from numbers to talk about processes. I am concerned about the reluctance of younger practitioners to enter general practice in many parts of the country, leaving it often to only elderly GPs to carry on as single practitioners, supplemented by agencies and bank locums. Do the Government really feel that that is satisfactory and sustainable?

I have a personal problem with this in Windermere at the surgery I am registered with. It operates from a fine purpose-built building but has been without a permanent GP for a number of years. It functions largely due to the skill, experience, training and commitment of nurse practitioners and other staff with specialist skills. Their work is supplemented by local doctors—if they can be persuaded to come. Five years ago, the practice was leased to a private company, OneMedical Group, 80 miles away in Leeds. Last autumn it took advantage of a break clause in its lease and surrendered it, and we are back to square one; it is far from a satisfactory situation.

The key issue is that younger GPs do not wish to buy into practices which might involve hundreds of thousands of pounds. I know a number of practices in Cumbria have had to undertake severe reorganisation and mergers simply to survive. In a letter to the Guardian on 1 March, a GP who has worked in the NHS for over 30 years made the same point, that younger GPs will not buy in to practices. I ask the Minister the most critical question that I am asking today: is this model, requiring such large financial commitments by individuals, suitable to the 21st century? Would the department do a preliminary examination of this problem?

The pandemic has changed so much, and we were found wanting. The years of austerity caused serious damage to our NHS. Only because of the beliefs of our NHS staff are we getting through it. One thing is clear: there is increased demand on our health service. There will have to be much change, including permanently increasing spending. The Government will have to recognise that what may have worked in the past may not do so in future. Models which have been sacrosanct may need to be examined and, if necessary, changed. All this is essential, with a radical White Paper bringing health and social care together. I ask the Minister: are the Government up to it?

My Lords, the NHS workforce has been working flat out for a year now. Their dedication, professionalism and personal sacrifices have inspired the whole nation. Vacancies stood at over 100,000 before the pandemic. The NHS now faces a huge backlog of operations with an exhausted workforce and increasing levels of sickness absence. Moving forward, a fully funded workforce plan is critical and must take priority over reforms to NHS structures.

I recently spoke to two very senior nurses working in London ICUs, who told me that what they need more than anything was time off for recovery and additional nurses to provide pre-pandemic levels of patient care.

The recent report of the Public Services Committee, looking at the lessons of Covid-19, received compelling evidence that other European countries have considerably more critical care beds per head of population than we do. Does the Minister agree that, if the pandemic has taught us one thing, it is the need to adopt the rainy day principle and build spare capacity in for future crises?

My Lords, I recognise that the Government want to address the issue of the NHS clinical workforce. The problem is not the ambition, but in having a clear long-term strategy to achieve this. Does the Minister agree that previous attempts have failed? The intensity and stressful nature of the work related to Covid and other factors, such as the recently announced pension cap, may make retaining staff difficult?

Recent surveys by the Royal College of Nursing, the Royal College of Physicians, the British Medical Association and many others have shown a very high proportion of the workforce are unhappy about their work, with low morale and mental health issues particularly related to Covid. With advances in care, NHS England is likely to require a growth in workforce of 3.2% per year over the next 15 years. That is nearly 650,000 full-time equivalent staff over the next decade. There are also issues about managing the workforce. I hope that through the new NHS Bill we can explore a long-term solution through legislation. Maybe the Minister would welcome that.

My Lords, I am most grateful to the noble Lord, Lord Clark of Windermere, for securing this short but important debate. It is always a pleasure and a privilege to follow the noble Lord, Lord Patel. I do not intend to repeat all the alarming statistics since it is abundantly clear that we are facing a crisis in the NHS workforce that is likely to get worse post Covid and which requires a co-ordinated long-term strategy. The numbers speak for themselves.

Our debate today is not just about the recruitment and retention of front-line NHS and social care staff. It also raises the issue of an ever-growing demand that drives the need for a larger workforce. There are, of course, many reasons for that, not least long lives and multiple morbidities, but alongside those go questions about lifestyle, behaviours and personal responsibility. The recent White Paper Integration and Innovation emphasises the importance of public health. What plans might Her Majesty’s Government have for making prevention a key part of their strategy for workforce development?

My Lords, with my minute I would like to highlight specifically those involved in treating perinatal mental illness. As many as one in five women experience mental health difficulties during pregnancy or after childbirth. The NHS long-term plan addressed that and workforce numbers are starting to move in the right direction, although we are playing catch-up in what has been a long neglected area.

The pandemic has resulted in women missing out on vital face-to-face interactions with health workers and support groups, so it is not surprising that during my research I found that many health professionals fear an epidemic of post-natal depression in particular. I would like my noble friend to ensure that his department reviews this, recognising that it is about not just workforce numbers but adequate training to spot early signs and to give women the personalised understanding that they need. Sadly, some women may not have felt able to speak up during the pandemic, so we do not know what the long-term effects will be on the demand for services, and I urge the Government to keep that at the forefront of their mind in their workforce planning.

My Lords, I declare my interest as a member of the GMC board. The NHS has responded magnificently to Covid but its underlying problems still exist. As the Health Foundation’s Jennifer Dixon put it, the NHS is under-resourced, under-doctored and under-nursed. The foundation forecasts that by 2033-4, vacancies will exceed 475,000 full-time equivalent, and even more will be needed to meet rising expectations and the impact of a growing older population. Yesterday’s Budget revealed a cut in spending for the Minister’s department of £30 billion from April and social care reform has once again been kicked into the long grass, so where is the long-term approach to the NHS and social care? Where is the long-term approach to workforce planning that is so desperately needed? Where is the innovation?

The GMC has used emergency powers to grant registration to over 25,000 doctors so that they can support the pandemic response, but most of them have still not been deployed. What a missed opportunity to bring those doctors back permanently to alleviate our workforce shortages.

My Lords, the NHS is critically short of staff so it is a credit to all that over the pandemic the amount of care given increased by one-third with the total workforce short by 84,000. The scale and complexity of care have risen considerably over the last few years, and I trust that the NHS pay review body will take all this into consideration.

Our Chief Nursing Officer has £28 million to recruit internationally nurses and midwives who are keen to join the NHS front line. The global market has widened for the ethical recruitment of health and care staff by aligning with the WHO code of practice. How many overseas nurses does the CNO hope to recruit? The forthcoming health and care Bill, which I hope is innovative, puts a duty on the Secretary of State to report on workforce planning responsibilities, which would be an ideal opportunity for parliamentary scrutiny. Maybe then we can revisit the issue.

We are having difficulty hearing the noble Baroness. We will come back to her after the next speaker, the noble Lord, Lord Willis of Knaresborough.

My Lords, I will make a very brief reference to a group of NHS staff who have gone largely unnoticed during this pandemic and the debate but have been trailblazers and lifesavers in equal measure. I refer to the newest recruits in the registered healthcare workforce, nursing associates. The nursing associate register commenced two years ago, and today there are 4,036 registrants with a further 7,000 who commenced training at the height of the pandemic. Many plan to train on as registered nurses. These remarkable people, most of whom were dedicated care assistants, have risen to the greatest nursing challenge ever seen, saving patients and, indeed, the NHS. What steps are the Government taking to recognise the contribution of nursing associates and to redouble the investment in the recruitment and training of future cohorts?

I will move to the next speaker, the noble Baroness, Lady Altmann. We hope by the end of her speech to have resolved Baroness Greengross’s communication issue.

My Lords, I am pleased to see that the numbers applying for nursing have been increasing. I know that the Government have started on their task of recruiting 50,000 more nurses by the end of this Parliament. What progress has there been towards that target? More crucially, what is the plan for improving retention rates in the NHS, as well as recruitment? Is there any further plan for improving recruitment and retention in the social care sector, which has not been mentioned so far?

I know that there is also a potentially significant issue with GP shortages being caused by early retirement, which has been encouraged by pension rules. Is there a plan to look into that issue as well?

My Lords, as the noble Lord, Lord Clark, outlined, we have for years failed to train the medical staff we need. To take doctors, for example, the numbers are astonishing: over one-third of our doctors—35%—obtained their qualifications overseas, yet in both France and Germany the figure is below 10%. Meanwhile, some 8,000 British applicants are being turned away every year.

The figures for nursing are even worse. Until 2016, more than 30,000 UK applicants were turned away every year, while tens of thousands of nurses were recruited from abroad, often from countries that need them far more than we do.

Finally, the Covid crisis is an opportunity for a major reform of medical training. I certainly hope the Government will take it. The NHS’s standing has never been higher and the number of volunteers has never been greater. We need some firm action. Our young people deserve these opportunities. I look forward to the Minister’s response.

My Lords, I am co-chair of the All-Party Group on Adult Social Care. Our recent report found that the government target of recruiting 20,000 additional social care workers was not enough—[Inaudible.]

I am sorry; I think the difficulty is that the noble Baroness is not close enough to her microphone. When she was tested, it was fine. If we cannot hear her again, perhaps she could write and the Minister will pick up the issues she would like to raise? I will give the noble Baroness one more try right now.

I am sorry; our connection is just too poor for us to hear the noble Baroness. If she could send an email in, the Minister will pick up the issues when he sums up. I thank her very much for her patience.

I call the noble Lord, Lord Winston. No, the noble Lord has withdrawn. I call the noble Lord, Lord Balfe. No, he has withdrawn too. I call the noble Baroness, Lady Bennett of Manor Castle.

My Lords, I am indeed here. I have one minute and two points. First, on recruitment and training, the World Health Organization reports that there are 28 million nurses worldwide but a 5.9 million global shortfall in the number of nurses needed. One in every eight nurses practises in a country other than the one where they were born or trained. The UK is a wealthy country and is traditionally a large importer of this scarce and valuable human resource, which other speakers have referred to. Surely we should be training sufficient numbers of nurses for our own needs and more. I note recent figures that UCAS has received 48,830 applications for nursing courses in England, up from 35,960 at the same point last year. In the continuing emergency situation, will the Government ensure that everyone who wants to study nursing gets a place, and will they agree to the Royal College of Physicians’ request to double the number of medical school places?

Secondly, on retention, for which one requirement is surely decent pay, there are many reasons to give the NHS a pay rise that I hardly need to list. However, I note that research by independent analysts London Economics found that 81% of the cost of an NHS pay rise would be recouped by the Government through additional taxes paid by the employee and employer, taxes earned through the greater economic activity that the pay rise would generate, and higher loan repayments by recent graduates. So why not a pay rise?

I offer tribute to our local NHS staff, those hard-pressed, weary, dedicated, resourceful, very local nurses and GPs and ever-courteous volunteers aplenty. They, the nurses, have injected tens of thousands so very professionally. Daily, we queued in our hundreds at the Deeside Leisure Centre. We sought immunity and we got it—the heroic nurses gave it. The nurse and the gatekeeper GP are the backbone of the NHS. We need more of them, urgently, and let us reward the heroic nurses better.

My Lords, I was appalled to read last week that the Government now say that recruiters for the NHS and care homes can actively target 105 countries that were previously blacklisted on ethical grounds. These countries include Zimbabwe, Jamaica, South Africa and India, all of which have an acute shortage of doctors and nurses. India, for example, has 0.8 doctors per 1,000 people—the UK has 2.8 per 1,000 people. It is therefore ludicrous for the Government to say that recruitment from these countries has suddenly become ethical. It has not.

We need a proper workforce strategy. As a result of Covid and the great work of existing NHS staff, wherever they come from, there is real enthusiasm among young British people to work for the NHS—applications for nursing courses, for example, were up by 35% last year —yet medical school places increased by a paltry 500 in the last year for which I have figures. There is a double betrayal here: of those in poorer countries whose doctors and nurses we are stealing, and of the unemployed in this country who we are failing to train. It is shameful.

My Lords, the Government must tackle the long-term underlying problems of training clinical and associated healthcare staff in a sustained and future-proofed way. We had serious gaps in capacity long before the Covid pandemic.

During Covid, exhausted and stretched staff have doubled, or even tripled, ward capacity in a makeshift manner to save lives over the past year. We must be better prepared for the future. Will the Minister commit to increase funding for the workforce development budget and internal education? We need a flexible, nurtured, resilient workforce to face the health challenges of tomorrow and incentives to retain our excellent NHS heroes.

These issues were urgent prior to the pandemic, and this has been a contributing factor to the appalling death toll in this country. The Government must make fully funded workforce planning a central aspect of any upcoming reforms.

I congratulate my noble friend Lord Clark on this debate. He is such a great champion of nurses; they could not have a better one. I also echo the request by the noble Baroness, Lady Bennett. Why not have a pay rise for nurses, paramedics and other NHS staff? It is a bit of a slap in the face not to have one.

At least 230 NHS staff have died during the pandemic, while thousands have been on long-term sick leave as a result of working on the front line. The Government have often cited their success in recruiting new nurses, saying that record numbers are working in the profession. However, the number of unfilled nursing posts in the NHS has barely changed. Can the Minister explain why there is not a publicly available, fully funded, long-term workforce plan for the NHS and social care to boost the numbers of nurses and NHS staff? I am sure that he would agree that the workforce remains key to the next phase of dealing with the pandemic and its aftermath.

My Lords, I am hugely grateful to the noble Lord, Lord Clark of Windermere, for securing this very important debate and I pay tribute to his campaign on this subject. I also thank all noble Lords who have spoken so well in such a short amount of time. There is clearly widespread agreement that building a resilient NHS workforce to meet the future needs of this nation is essential, and I completely agree.

I also echo the thanks of the noble Lord, Lord Clark, for the extraordinary contributions of health and care workers across the UK during the pandemic. It is important that we recognise their extraordinary efforts. With the exceptional success in the UK of the rollout of the vaccines programme, we are at last approaching a time when the worst of the pandemic is over and the NHS can return to its business as usual—caring for the nation and providing world-leading healthcare.

I will say a word about the long-term plan. A £3 billion, one-year package has been announced for 2021-22 as part of the spending review to support the NHS in tackling the impact of Covid-19. This will include £1 billion to address backlogs and tackle the long waiting lists raised by noble Lords, by facilitating up to a million extra checks, scans and additional operations.

As the NHS gets to grips with the backlog of care, it is essential that we continue to change the way we deliver healthcare over the next 10 years. All those who spoke about innovation are absolutely right in that regard. We have a road map to do just this in the NHS long-term plan, which clearly sets out a new service model for the 21st century: more care delivered in the community, digitally enabled primary and outpatient care, and a relentless focus on the health of the local population and reducing health inequalities. I reassure the right reverend Prelate the Bishop of Carlisle that the plan absolutely identifies how we can make better use of early diagnosis and technology potentially to improve preventive care, population health and patient care. This will be supported by new and integrated models of care, as laid out in the NHS Bill.

I shall say a few words about staff retention. To do these things, we need more staff, yes, but critically we need to hold on to those that we already have for longer, help them to recover from the herculean efforts of the pandemic, nurture their skills and enable them to provide the care to patients that drives their efforts. The commitment of staff and the wider impacts of the pandemic mean that the NHS continues to see much stronger retention rates.

Despite that, troubling issues need to be addressed to ensure that dedicated NHS staff have the best possible experience of work. The noble Baroness, Lady Tyler, made an absolutely fair point on the need for a holiday. Our black and minority ethnic staff, in particular, report some of the poorest workplace experiences. I remind the noble Baroness, Lady Thornton, that the NHS people plan sets out exactly the kind of programme that she called for to tackle these issues, and we will continue to strive every day to ensure improvement on that front.

I come to NHS workforce growth and planning. The workforce has increased by over 160,000 already since 2010, an increase of 16%. This growth continues to be a key focus to ensure that we meet the rise in demand for health and care services. The 2020 spending review provided £260 million to continue to grow the NHS workforce and support commitments made in the NHS long-term plan. Nursing is absolutely the most critical component in this vision. I am pleased to report to the noble Lord, Lord Clark, that we are on track to deliver 50,000 more nurses by the end of this Parliament and put the NHS on a trajectory to a sustainable long-term supply in future. The 50,000 commitment is underpinned by a robust delivery programme, which will be achieved through increased domestic and international recruitment, and improved retention. The latest NHS workforce statistics show that nurse numbers have increased by almost 10,600 from almost 289,200 to over 299,700 between December 2019 and December 2020.

To reassure the noble Lord, Lord Clark, and echo the noble Baroness, Lady Bennett, the future domestic pipeline is strong, with UCAS end-of-cycle data showing 25,000 student nurses enrolled on courses in 2020-21. This is a 27% increase. I must say to the noble Baroness, Lady Bennett, that we cannot give everyone a place. As I am sure she knows, the job is highly skilled; it is a very difficult vocation, and it is extremely hard work. Not everyone is suited to it. More recent UCAS data shows unique applicants to nursing and midwifery courses in 2021 have increased dramatically to 48,300, or by 34% compared with last year. I hope that that provides some reassurance to my noble friend Lady Wyld.

On primary care, we are equally committed to growing the workforce and expanding the number of appointments available to patients. This will mean improved access to GP services and bigger teams of staff. On the reservations expressed by the noble Lord, Lord Clark, on the GP model, we are completely open to change: we have already looked very carefully at the independent review partnership model, the GP fellowship scheme and other schemes for GPs. But, with record numbers of GPs being recruited at the moment, it is too early to call time on the successful existing model. We have committed at least an additional £1.5 billion in cash terms for general practice over the next four years for additional staff. We will grow the workforce by 6,000 more doctors and 26,000 more primary care professionals. As of December 2020, there were 438 more full-time equivalent doctors compared with a year before.

Education was raised by many noble Lords. The Government have funded an extra 1,500 undergraduate medical school places per year in England—a rise of 25%. I reassure the noble Lords, Lord Willis and Lord Green, that the number of medical school training places will rise to 7,500 each year. We have also delivered five brand-new medical schools: in Sunderland, Lancashire, Chelmsford, Lincoln and Canterbury.

My noble friend Lady Wyld made extremely good points on the importance of perinatal care—a subject in which we share a keen interest.

UCAS data shows that there has been a large increase in the number of applicants to study medicine this year, with almost 5,000 additional applicants compared with 2020.

International recruitment was raised by a number of noble Lords. There is excellent growth in our domestic workforce, but we do still value the workers from all over the world who are playing a leading role in the NHS’s efforts to tackle coronavirus and save lives. We have made £80 million available for the recruitment of overseas nurses and the recruitment of healthcare support workers. Trusts are working hard to fill these nursing positions.

To the noble Lord, Lord Jones, I say that there is nothing ethical about blacklisting healthcare staff from certain countries.

In response to the noble Baroness, Lady Jolly, I say that I do not have the precise number to hand, and I suspect that it is not in the public realm, but I will try to find it and send a note to her. Perhaps I can reassure her that the supply of international nurses wanting to work in the NHS remains strong and, in spite of travel bans in some places, we are seeing more nurses arrive all the time. We have recently published our code of practice for the international recruitment of healthcare professionals, which will ensure that the UK is a world leader in ethical international recruitment and will, I hope, go some way to reassure the noble Lord, Lord Jones.

I reassure my noble friend Lady Altmann that we are also doing more to attract people into social care. We ran a national recruitment campaign across broadcast, digital and social media. The latest phase in the campaign was launched in early February, highlighting the vital role that the social care workforce has played during the pandemic.

On pay, while most pay rises will be paused in the rest of the public sector for 2021-22, the Government recognise, as does the noble Baroness, Lady Thornton, the uniquely challenging impact of Covid-19 on the NHS, so we will continue to provide pay rises for NHS workers, including nurses. For recommendations on pay we are looking to the independent pay review body and will carefully consider its recommendations when we receive them.

A number of noble Lords touched on staff coming back from retirement, which has been raised in previous debates. The noble Lord, Lord Hunt, raised this point. I acknowledge that former healthcare professionals came forward in extraordinary numbers to support the NHS during Covid-19, and we are enormously grateful for their response. Due to the postponement of elective care, the skills and experience of many of these professionals were not deployed at the time—the noble Lord, Lord Hunt, was entirely right to make that point. We need to understand the reasons for that more clearly and to learn lessons for the future—I acknowledge that. In many areas, hospitals preferred to make more use of their existing staff rather than take on unfamiliar staff in a time of pressure, where teams were dependent on trusting relationships to manage the crisis. In future we need to ensure established ongoing relationships at local level, so that when the need comes again—as I am sure it will—this invaluable and public-spirited resource can be quickly deployed to ease pressures.

I am confident that there is the potential to build a permanent legacy through the development of a form of NHS and care reserve, which could help former healthcare professionals remain part of the NHS family, keep their skills up to date and provide additional support in times of pressure. NHS England has been piloting models for an NHS reserve across the regions of England. NHSEI has established seven pilots, one in each region of England. It is drawing on the learning from these pilot sites, the experience of the Bring Back Staff programme and five subject-specific national framework task and finish groups to investigate the best way forward to make additional flexible workforce resources available to the NHS.

I finish by reassuring noble Lords that growing and supporting the NHS workforce is a key priority for this Government. The breadth of our work, which I have only touched on today, should be a testament to the Government’s focus on this essential mission.

Sitting suspended.