Committee (5th Day)
Relevant documents: 15th and 16th Reports from the Delegated Powers Committee and 9th Report from the Constitution Committee
My Lords, before we formally move into Committee on the Health and Care Bill, I will raise a matter of general importance about the parliamentary process upon which we are embarked and seek guidance from the Government about a serious matter which is of immediate concern in the parliamentary process we are currently undertaking. I have no wish to delay proceedings so I will get to the point.
In August, the Government and NHS England issued a Readiness to Operate Statement guidance and checklist to all the relevant parts of the NHS concerning planning for the forthcoming legislation. On 19 January this was updated concerning the ICB establishment timeline, regarding the implementation date for the legislation moving from April to July. The words “subject to parliamentary process” may have been included in the guidance but the actions which flow from the NHS England guidance are contrary to those words. For example, it seems that the latest advice from the Government and NHS England confirms deadlines for appointments of leaders, chairs and boards, many of whom have been appointed, possibly involving the spending of public funds, long before the Bill has completed its passage through Parliament. Indeed, there are many other matters which are still subject to parliamentary process. This is pre-emption of parliamentary process.
The issues in the guidance are at the forefront of the Committee’s deliberations and it is possible that much may have changed before the Bill receives Royal Assent. Our scrutiny in your Lordships’ House is important, not least because both the Constitution Committee and the DPRRC have been highly critical of the Bill and the department. They have stressed the importance of the Bill receiving sufficient scrutiny, since it did not have pre-legislative scrutiny and is significant “disguised legislation”, including more than 60 delegated powers and directions which have no parliamentary process at all.
Noble Lords will be familiar with the rules governing preparation for the enactment of legislation. After Second Reading of a Bill, some work may be undertaken, but guidance from Her Majesty’s Treasury in May 2021 is very clear what actions can and cannot be taken. Box A2, point 4C, refers to:
“Expenditure which may not normally be incurred before royal assent.”
First, there is,
“significant work associated with preparing for or implementing the new task enabled by a Bill, eg renting offices, hiring expert consultants or designing or purchasing significant IT equipment”.
Secondly, there is,
“recruitment of chief executives and board members of a new public sector organisation”.
Thirdly, there is,
“recruitment of staff for a new public sector organisation”.
We understand that NHS England was advised by others not to issue this guidance. Will the Government confirm that: first, the legitimate role of this House in the scrutiny of legislation should be made clear to NHS England; secondly, the current guidance will be withdrawn and it will be made clear to NHS England that further action must await the completion of the Bill and Royal Assent; thirdly, it will be made clear that aspects of the changes within scope of the Bill can and may well be amended; fourthly, that adequate time will be allowed for proper scrutiny of the Bill? I shall be referring the guidance to the two said committees. If the Minister is unable to provide a response today, please can he confirm that he will respond in writing by the end of the week; otherwise, we will need to raise this again in your Lordships’ House?
I start by thanking the noble Baroness for giving me advance notice of her intervention today. It clearly reflects the mood and concerns of the House that we heard last week. We recognise the strength of the House’s feeling on this matter. I have spoken to my department, and it told me that it is meeting NHS England this week to discuss this matter, and I will update the House accordingly. On the request that the noble Baroness made, I commit to write to her.
Clause 20: General functions
72: Clause 20, page 17, line 4, at end insert—
“(2) Where patients are unable to secure treatment in an NHS facility after waiting 3 months, they may choose to seek treatment, including diagnostic treatment, from a registered private service provider at NHS prices.(3) Providers of services under subsection (2) must provide NHS England with the information NHS England considers necessary to enable it to conduct and publish a national annual survey on the extent to which patients have been offered a choice of provider.”
My Lords, the first part of this amendment links the issue of patient choice to tackling the serious problem of huge NHS waiting lists. We cannot have a meaningful policy of patient choice in the area of elective treatment without sufficient NHS capacity. Many parts of the NHS lack that capacity and will do so for a long time to come unless they draw on independent sector capacity or spare capacity in other parts of the NHS. In short, the NHS must accept a degree of competition in the area of elective diagnosis and treatment if it is to reduce huge backlogs. That extra capacity and choice was being put in place at NHS prices 15 years ago, when at least half the country had that choice. Since then, the situation has deteriorated, but that is the direction of travel that we need to return to now if we are serious about removing patients from the huge NHS waiting lists.
The evidence for the seriousness of the situation that the NHS faces was set out in a National Audit Office report published in early December 2021. It revealed that 6 million people in England are on waiting lists for elective care, with 300,000 of them waiting over a year. The NAO also estimated that, between March 2020 and September 2021, there were between 7.6 million and 9.1 million fewer referrals for elective care. It is unclear whether or when these “missing people” will seek NHS treatment. However, if half of the missing referrals for elective care do return, and assuming that NHS activity improves by 10% more than its pre-pandemic levels, which is what the Government are expecting for the extra £8 billion that they are investing by 2025, the NAO considers that there will still be 7 million people left on the waiting lists in 2025.
So, can the Minister tell me whether the Government accept the NAO’s analysis and calculations? How much elective capacity—NHS or independent sector—will the Government fund in the next two financial years to reduce elective care waiting lists? Are there any plans to encourage patients to choose other NHS hospitals or private hospitals instead of waiting for their local hospitals to get around to treating them? If he cannot answer these three questions today, I should be grateful if he would write to me with answers, as a matter of some urgency.
Before I turn to the second part of my amendment, can the Minister clarify the significance of the front-page story in the Times of Tuesday 18 January, which might have a bearing on my amendment and the Bill more generally? This headline read, “Javid plans NHS revolution modelled on academy schools”. As a former Blair Health Minister, I commend the Secretary of State for moving in this direction, but how can such a move be compatible with the current Bill? If the Times article is accurate, it would seem to have implications for the new provider selection regime provided for in the Bill. However, I am reliably informed that the draft regulations governing the new regime have yet to be published.
So are these regulations being held up because the Secretary of State is changing his policy? Certainly, I know—the matter has been impressed on me—that independent sector providers are unclear about the arrangements for providers to appeal against ICS decisions that are at odds with the regulations. I am assuming of course that ICS will not be allowed to mark its own homework, but can the Minister clarify when there will be a public sighting of the draft regulations? Again, if he cannot say today, I should be grateful if he would write to me.
Finally, I turn to the right of patients to choose where they receive care. I will not go over the period 15 years ago when a lot of progress was made on the reality of patient choice, but I will mention some King’s Fund research in 2011 which drew attention to a significant barrier to exercising that right. That barrier was NHS staff. If patients are not informed of their choices and are discouraged from exercising them, they will go on forlornly waiting for their local hospital to get around to treating them. Rights can be enforced only if there is information available. This is the purpose of the second part of Amendment 72. My information is that not since 2015 has NHS England published an official annual survey of whether patients have been offered a choice of provider when receiving treatment. That is why we need a statutory provision that provides for the regular measurement and public reporting of patients’ experience in whether they have been offered choices about their care.
I have made it clear that I am deeply sceptical about whether some parts of the NHS are really committed to patient choice—because of fears that it would lead to people travelling for elective care that is more readily available elsewhere than in their local hospital, which, in turn, might lose income. If I was unkind—I am not—I would say that, for many NHS staff, local monopoly trumps patient choice. That is why I have put down this amendment. With the huge backlog of elective care, I want to give patients a clear statutory right to shop around for treatment, if the local hospital has failed to provide it within a reasonable period of time. If the Minister doubts my arguments, he might like to look at some LSE research by Zack Cooper, published in 2011, which showed the benefits of NHS patient choice and competition.
We need Amendment 72 in order to provide greater certainty for patients to be able to choose elective care providers, to reduce the enormous backlog of treatment and to send a message to NHS staff about the rights of patients. I hope that the Minister will accept these arguments and will be able to answer my questions. I beg to move.
My Lords, I support Amendments 109 and 226 in this group, both of which are in my name and that of the noble Lord, Lord Hunt of Kings Heath. I will address them from the perspective of people with diabetes and with the support of the Juvenile Diabetes Research Foundation and Diabetes UK.
It is just over 100 years since insulin was discovered. Before 1921, a type 1 diabetic would live for no more than a year or two from when the condition became discernible. In the 1920s, my father, a World War I veteran, developed diabetes, and he was very fortunate that this was the decade in which insulin was discovered. It was so successful that it enabled him to have a long and happy life—indeed, I was born when he was 71, and my younger brother was born when he was 73.
Much progress has been made in the treatment of diabetes over the last 100 years, but we are not making the most of technological developments relating to insulin use and diabetes management. I have struggled with these issues myself, and I have learned much about them since I became dependent on insulin in 1994. I personally have enormous reason to be grateful to the diabetic team at St Thomas’ Hospital, just over the river from us, but not everyone with diabetes gets that standard of care, and progress with the adoption of the most recent technology is simply too slow.
There have been great developments in wearable medical technology, such as insulin pumps, flash glucose monitoring and continuous glucose monitoring. We are making progress with such innovations and in NICE’s obtaining approval for them, but they are often not widely accessible. Access to technology, including linking a person’s insulin pump and a continuous glucose monitor, may help a person to self-manage their condition in the absence of routine NHS support. The long-term cost savings are demonstrated by the wider use of such technology in insurance-based systems, where the outlay must be justified by reducing the costs of later complications, which can be very considerable.
Diabetes probably now takes up 10% of the NHS budget, and 80% of the cost of diabetes relates to complications, with the largest costs arising from excess in-patient days, cardiovascular disease and damaged kidneys and nerves. The latest technology may enable parents of young people with type 1 diabetes to obtain a full night’s sleeping soundly, knowing that their child’s glucose monitor will issue an alarm and wake them up if they experience a severe high or low-glucose episode. New technology has been shown to support blood glucose stability and to lower average blood sugar levels, reducing potential health complications and hypos or hypers, which can lead to coma or even death if not treated. There are great benefits to physical and mental health from better long-term control of blood sugar levels.
Research by JDRF shows that barriers to the uptake of this technology include the fact that many clinicians are not trained in it and that the pressure on appointments means that there is often not time to discuss treatment options. Amendment 109 would require NHS England’s oversight framework for integrated care systems to include a metric on the percentage of diabetes patients in their area accessing diabetes technology. An embedded requirement that would better support the prescription of technology would incentivise better training for clinicians and encourage more time to be provided in appointments to discuss technological treatment options and any potential fears or concerns of the patient.
Amendment 226 concerns the promotion of self-management using the latest technologies. We need it in order to reduce the number of people with diabetes suffering from complications, which may include sight loss and problems with their feet, presently resulting in around 6,000 amputations per year. When in hospital, people with type 1 diabetes require five times more secondary care support than people without diabetes, so it is essential that the NHS invests in technology that can significantly reduce the instances of hospitalisation and adverse health outcomes for people with type 1 diabetes.
My Lords, I thought those were very interesting and helpful remarks from the noble Lord, Lord Rennard. They serve to remind us of the importance of self-management in securing the best possible outcomes for patients. I just add the thought that, when the Government promulgate regulations relating to patient choice, one of the things we want to include is shared decision-making between clinicians and patients. In my observed experience, that too can deliver better outcomes. I think we have made significant progress in recent years in encouraging shared decision-making, and I hope we will see that come forward.
In moving Amendment 72, the noble Lord, Lord Warner, touched on a range of issues. I will not go down one or two paths, but I highlight that we will need to think hard about the interconnections between the question of patient choice and how far patients continue to be given choice. We need to ensure that it is not just talked about in the constitution or in regulations that say it is generally a good thing. For choice to happen in practice, subsequent clauses in the Bill relating to procurement, such as Clause 70, need to enable a choice of providers. The noble Lord made that perfectly clear.
The clause relating to payment systems—Clause 68, if my memory serves me correctly—still needs to have a “money follows the patient” approach. It is not me saying that these are all good things; they were put in place by the Blair Government, not the coalition Government, who did not do away with them but entrenched them.
I am worried. I will just make this point about Clause 70, the effect of which is to repeal Section 75 of the 2012 legislation. Included within that was that one of the requirements of the procurement regulations would be to support the right to patient choice, and the Government are proposing to repeal that.
The Minister may well, perfectly correctly, say, “That may be so, but we have the power in this Bill to set regulations relating to patient choice”, but this is separate, and, in the event, we may find that the link is broken between procurement and payment and patient choice. The net effect would be that patient choice is vitiated. I am worried, for exactly the reasons that I think the noble Lord, Lord Warner, is worried, that what has been around for some 18 years in one form or another—the expectations on the part of patients that they can exercise choice—may not be able to be exercised in practice because the preference of the NHS in many of these localities is to operate as a monopoly and not to give any opportunities for that choice actually to function.
Our debate on this group would be far better and easier to have—and might not even be needed—if the Government published the regulations under Clause 68 in draft so that we can see what they are proposing to do. They have not done it; between now and Report they could do it. When we get to Report, we are going to have a very difficult—certainly from my own personal point of view—set of conversations about how patient choice is to be exercised, how the NHS is to get best value from its procurement, and how trusts and providers are to be paid appropriately, rather than simply go back to block budgets. How do we get out of that debate? The answer is: let us see what the regulations the Government are proposing—in this case relating to patient choice—actually look like, and let us see it before Report.
My Lords, I put my name to Amendments 109 and 226, in the name of the noble Lord, Lord Rennard. I also have my own Amendment 204, which I will not move or speak to, because we dealt with Healthwatch in a debate which seems a long time ago but was only two Committee sittings ago.
I refer to the remarks of the noble Lords, Lord Warner and Lord Lansley. It seems to me that behind this is the hard issue we face that the huge increase in the number of people waiting will, I am afraid, take us back to the very bad old days of the perverse incentives existing within the NHS for patients to be encouraged to go for private care because of the length of the waiting list and waiting times. The noble Lord, Lord Warner, will recall that under the Blair Government, as part of our attack on waiting times, we had to tackle this issue of certain consultants—I suppose I should declare my interest as a member of the GMC board, though I am certainly not speaking on its behalf—and certain perverse incentives for patients to be encouraged to go to the private sector. Of course, much maligned though they were, that was why independent sector treatment centres were set up, and they were part of the process of driving waiting times down. We now have a huge problem of huge waiting times and a huge number of waiting lists, and we have to be very careful to ensure that these kinds of perverse incentives do not come back into the health service.
Does the noble Lord recall that, when independent sector treatment centres were established, they operated on the basis of NHS prices, so people were getting NHS treatment in these independent sector treatment centres at the same price that the NHS would have had to pay for that treatment?
My Lords, that was a very important intervention, and I am grateful to the noble Lord for jogging my memory. I think that he would agree, though, that apart from the price, the point was that it was an important element in getting waiting times and waiting lists down. At the moment, we are clueless about how the Government are going to do this. As the noble Lord, Lord Lansley, said, we will have a debate—I hope tonight—in relation to procurement, but I say to the Government that the open-ended nature of the regulation-making power that they propose to give to Ministers in such an important area is utterly unacceptable and has been drawn to the House’s attention by both the Delegated Powers and Regulatory Reform Committee and the Constitution Committee, as the noble Lord knows.
This is a very curious group. I shall just mention the two amendments to which I have put my name—though I think the noble Lord, Lord Rennard, has said it all—and refer to the importance of self-management. The evidence in favour of self-management is overwhelming. I refer the House to the data analytics team at the Health Foundation, who have begun to fill some of the evidence gap in relation to this. They have shown that the patients most able to manage their health conditions have 38% fewer emergency admissions and 32% fewer A&E attendances than those least able to manage their conditions; they also have 18% fewer GP appointments. This is the first study in the NHS to have demonstrated an association between a patient’s ability to self-manage and the use of services across primary and secondary care. That is an important start to an evidence base. The Minister has not been sympathetic to many amendments; it has been warm words but little action so far. I hope that, on our fifth day in Committee, on these two amendments put forward by the noble Lord, Lord Rennard, the Minister might just say that he will accept them.
My Lords, this has been a very interesting short debate. I have two issues to raise. I am grateful to the noble Lord, Lord Hunt, for having raised perverse incentives and, indeed, the danger with perverse incentives that senior consultants with a great deal of experience could be absent from NHS premises when undertaking work such as surgery in other premises; they would therefore not be available to their NHS patients in the event of a problem and some surgery being left to more junior members of staff.
The other issue is the difficulty of ensuring true consent and information for patients when they are offered choice, with respect to their awareness of the staffing levels in the premises to which they will be going. In some of the private providers, there is not very comprehensive out-of-hours medical cover—particularly at night—with somebody on site. There is also a problem that, if a patient should develop a complication, foreseen or even unforeseen, and is in need of an intervention, they may then need to be transferred to a local NHS intensive care unit. In that event, it would be important for the money to follow the patient. If that intensive care unit is out of the area from which the patient has come, I hope that the regulations will allow for appropriate funding of that NHS facility.
Is the noble Baroness aware that, during the arrangements in which there were contracts with the independent sector to provide elective surgery in independent treatment centres, the quality of that care was both reviewed by the then Chief Medical Officer, Liam Donaldson, and looked at, with evidence taken, by the Health Select Committee? They found that claims about shortcomings in these private facilities were exaggerated—their provision of services was equally as good as that of the NHS facilities.
My Lords, I shall briefly support what has just been said by the noble Lord, Lord Hunt, and the noble Baroness, Lady Finlay, with a personal anecdote. When I recently needed an MRI scan on my neck, the doctor said, “Well, of course, you can have it done quite quickly if you go private.” She then added, “In case you are worried about doing that, it takes the pressure off of the health service.” The point made by the noble Lord and noble Baroness is exactly that it does not take the pressure off the health service; for the previous few weeks, these doctors have been working for the National Health Service. I hope that the Government will take this on board and will not start using the argument that going private takes the pressure off the health service.
Following on from that, one point that we should take into account is the extent to which the private sector and the NHS rely on the same workforce. That is particularly the case in relation to consultants and less so for nurses.
While we can argue about the location, price or quality, perhaps, of treatment and aftercare, the key issue is diagnostics, which is a huge issue at the moment in the NHS. I have a slightly different take on that. For all of my life, my mum was deaf, and I have to say that the quality of NHS hearing aids was about 10 years behind the private sector’s—but people trusted them; they trusted the quality of the diagnostics and the advice that they were given. We have moved a long way in terms of diagnostics for eyecare and hearing aids, but it does not matter where that happens; what the general public want to do is to be able to trust the quality and independence of the diagnostics that they get. If we can do that, I rather suspect that the general public, in the wake of the pandemic, when they see the NHS struggling in all sorts of ways to make up for two years in which their staff have been pulled around, sometimes away from their specialties, would be quite forgiving—as long as there are some very basic agreements about how it will work and the integrity of the work and systems.
I am most grateful to the noble Baroness, Lady Barker, for adding some clarification to the point that I was trying to make. I am not for or against any system; all I am saying is that the arrangements have to be in place so that nobody is jeopardised—and indeed, in the event of a patient being transferred from a private facility back into the NHS, that part of the NHS is appropriately recompensed, particularly if the patient comes from a long way away.
My Lords, the problem to which the noble Lord, Lord Warner, is suggesting a possible solution is the result of long-term underplanning and underfunding of staffing in the NHS, and underfunding also of the capital budgets of hospitals, which sometimes have to choose between mending the roof and buying a piece of equipment that would get patients through the system more effectively and efficiently.
On the comments from my noble friend Lord Rennard on self-management, it is of course not just better care that that produces—it is also very cost effective. I draw noble Lords’ attention to page 3 of the Bill, line 13, where one of the three things to which NHS England has to pay regard about the wider effects of its decisions is
“efficiency and sustainability in relation to the use of resources”.
The resources are much better and more efficiently used if the patient has a decent choice of the equipment and treatment that is most effective for them, and it is often a great deal cheaper.
I also agree with the noble Lord, Lord Lansley, that we need the guidance. We need to see it before Report, and I hope that the Minister will be able to provide that.
My Lords, these amendments stress the importance of patient choice in health management, especially of their long-term health conditions, and I welcome and endorse what noble Lords have said on these key issues. The vital importance of patient choice and their right to be able to make informed decisions about their conditions and treatment, and to receive treatment within the 18-week standard waiting time set out in the NHS mandate, was pioneered by Labour and continues to be fully supported by these Benches, as I stressed last week in the group of amendments on the mandate and the NHS constitution.
The noble Lords, Lord Rennard and Lord Lansley, and my noble friend Lord Hunt have spoken about the importance of active self-management, where clinically suitable, for patients with conditions such as diabetes. Access to the latest technologies varies greatly across the country, and the call in Amendment 109 to ensure that the oversight framework for ICSs includes systems for measuring the numbers of diabetes patients accessing diabetes technology would help achieve greater consistency and better use by patients who could benefit from it, particularly in helping to keep them out of hospital or to prevent their conditions deteriorating.
As vice-chair of the Specialised Healthcare Alliance, I know that patients with rare diseases often do not feel sufficiently supported in terms of psychological support, health systems and information, physical and daily living, patient care and support, and sexuality needs. As they are often having to live with their conditions long term, they have considerable potential to be more expert in their conditions than many of the healthcare professionals they come into contact with, many of whom may not be familiar with their disease or condition. With appropriate support, therefore, such patients can manage their less intensive care needs themselves, delivering better health outcomes and reducing demands on the NHS. Efforts to promote the self-care of people with health conditions, as set out in Amendment 226, really have the potential to improve the care of people with rare diseases.
Amendment 72—moved with his usual expertise and clarity by the noble Lord, Lord Warner—reinforces the importance of patient choice and is highly relevant because of the growing and record waiting list that we spoke about last week during the debate on the mandate and constitution. Of course, Labour in the past has used the private sector as part of a comprehensive plan to reduce waiting times, as the noble Lord, Lord Warner, pointed out. He will also know that in reality the role played by private providers, and the costs involved in getting the waiting lists down to the 2010 levels before this Government took office, particularly for elective surgery such as hip and knee replacements, were modest compared with the huge investment in the NHS itself and Labour’s genuine commitment to public service solutions, increased investment, the use of targets and improvements in pathways and other efficiencies. As a result, the private sector relied more heavily on getting business from the NHS on NHS terms, not actually treating private fee-paying patients.
In sharp contrast, we have the complete absence of such a comprehensive or coherent plan from the Government to reduce the now-record waiting lists, as the noble Lord, Lord Warner, set out in moving his amendment. The Secretary of State has acknowledged that waiting lists could grow to 13 million, with the National Audit Office now predicting that the situation could get even worse than it currently is by March 2025. The Secretary of State promised in November to publish how the Government plan to meet the workforce requirements needed to address staff shortages—to which noble Lords have also referred to during the debate—and the record waiting lists, but we still have not had any sight of this.
So far, all we have had instead are last week’s press reports of the huge sums of money the Government want to hand over to the private sector, including disturbing reports of NHS England’s unease at the Secretary of State’s instructions to hand over £270 million to the private sector with no guarantees on numbers of patients to be treated or, indeed, whether any NHS patients will even get treatment. Our shadow Secretary of State, Wes Streeting, has made it clear that an incoming Labour Government would fully expect again to use the private sector to help bring down waiting times for treatment, but as part of a comprehensive plan to build and the support the NHS so that people do not have to go private because waiting lists are at record levels and they are suffering and in pain. People who cannot afford it always have to wait and remain in pain. That is not social justice and it is just not right.
We support the principle in this amendment. If long waits can be prevented, they should be, although there is a serious question about whether the private sector would in any event actually have the capacity to meet the demand that could be generated by the three-month stipulation for treatment in the amendment. We also agree that the Clause 68 regulations need to be published as soon as possible and I look forward to the Minister telling us more about that. By contrast, a far better solution, as Labour has always advocated, would be to invest in the NHS, help the NHS become more effective and efficient and build capacity so there would be far less need for private sector care.
Finally, the amendment’s requirement to ensure that private sector providers have a duty to provide NHS England with annual information on the services funded by the NHS and on patient choice would be a welcome development, for the reasons that the noble Lord, Lord Warner, set out. The more that is known about the use of private providers, the better and more informed the discussion about their role will become. I look forward to the Minister’ response.
My Lords, I shall start by addressing Amendment 72 in the name of the noble Lord, Lord Warner. The Government are wholeheartedly committed to addressing the backlog of hospital treatment, much of which, as we are all aware, has resulted from the unprecedented efforts that our country and our health system have taken to combat the Covid-19 pandemic. This includes continuing to work closely with independent sector providers of acute care to provide the capacity to deliver more treatments and to reduce waiting times. I shall explain that a bit further. As of 10 January, NHS England has entered into national arrangements with 10 independent sector providers, to meet the needs of their patients and to reduce waiting times for treatment. This will also allow a wider range of patients to be treated in the independent sector, such as those needing some forms of cancer surgery and other treatments not normally delivered under existing arrangements.
The Government will continue to monitor this collaboration and work closely with the NHS and the independent sector to ensure that patients receive the best possible treatment and care. I welcomed the shadow Secretary of State’s comments on the use of private providers in recent weeks, supporting the use of the private sector where necessary to address the backlog.
We do not, however, believe that the amendment as written offers the right approach to effectively support collaboration between these parts of our health system at this time. The system already has arrangements between the NHS and the independent sector to address specific needs and to target areas where the greatest benefit can be gained. In addition, in most cases, patients already have the legal right to ask for their appointment to be moved to a private sector provider if they are likely to wait longer than the maximum waiting time specified for their treatment. This includes where patients have to wait more than 18 weeks before starting treatment for a physical or mental health condition, or more than two weeks before seeing a specialist for suspected cancer, with some specified exceptions. This does not limit patients to a private provider, as the amendment would, but allows them to choose from a range of providers. Currently, patients waiting for treatment are prioritised by the NHS so that those in the greatest need are treated first, when their clinical urgency and the length of time they have been waiting for treatment has been reviewed.
At present the NHS captures information on patient choice, which includes the use of e-RS at referral, where NHS England can see the number and nature of choices offered to patients. There is also a national e-RS pop-up survey for patients, which provides data on patient choice; information on choice offered to waiting list patients is also recorded.
The noble Lord, Lord Warner, wanted to know about the timing of the publication of the regulations on patient choice. That will be the same as for the provider selection regime regulations: as close to July as possible, subject to parliamentary passage.
The noble Lord also asked about work on the elective recovery plan. The Government have announced that we will spend £2 billion this year through the elective recovery fund to tackle the elective backlog, as part of the biggest catch-up programme in the NHS’s history. This will continue with £8 billion in the following three years, from 2022-23 to 2024-25, and a further £5.9 billion was announced in the October 2021 spending review to support elective recovery diagnostics and technology.
The independent sector is bolstering NHS capacity in a wider range of areas—MRI scans, providing cancer diagnosis and treatment, treating women with gynaecological health issues, and much more. Thousands of patients are receiving tests and treatments for a wide range of conditions, thanks to the arrangements in place in the NHS and the continued strong partnership with the independent sector.
The noble Lord, Lord Warner, also wanted to know about the story in the Times on academisation of hospitals. Significant NHS reform is already under way through this Bill, our plans for integration, the health and care levy, and our upcoming electives plan. No further plans have been agreed. High-quality hospitals will always have a central role in our health and care system, and the Bill will ensure that they do so in a way that supports integrated and patient-centred care.
I think that the noble Lord, Lord Hunt, said that he did not want to move Amendment 204, so I will not speak to that.
I thank the noble Lord, Lord Rennard, for bringing Amendment 226 before the Committee today. Supportive self-management is part of the NHS long-term plan commitment to make personalised care the norm. However, we do not believe that having an additional duty on NHS England, as proposed by this amendment, would further support this work. Indeed, having a stand-alone duty of this kind could make the work more disjointed, rather than complementing the existing holistic approaches to personalised care, which aim to empower individuals to live well with their conditions. The department is working with NHS Digital and NHS England and NHS Improvement to encourage innovative new approaches and organisations to support services and to collaborate in an effective way with the NHS.
Amendment 109 deals with the access to innovation technology among diabetes patients, and I thank the noble Lord, Lord Rennard, for bringing it before the Committee today. He is a much-valued contributor to all debates on this subject, and we learn something new ourselves every time he speaks on it. We have existing tools at our disposal to monitor the use of innovations. This includes NHS Digital’s innovation scorecard and the AAC scorecard. We are committed to further strengthening these innovation metrics and to improve our understanding regarding the use of innovations in the NHS.
This amendment seeks to add a new subsection to new Section 14Z49, which would create a requirement for guidance published by NHS England for ICBs to include performance metrics on the uptake of innovative technologies among diabetes patients. I understand that the amendment would seek to set specific requirements for the system oversight framework for ICBs in respect of diabetic patients. However, this could risk creating a confused system of reporting requirements, which I am sure we are all keen to avoid.
The amendment would also cut directly across the existing mechanism for setting priorities, by which the priorities set by the Government for NHS England, and in turn by NHS England for the system, are translated into reporting requirements—this flows from ICBs to NHS England and to Parliament. However, I hope I can give the noble Lord some reassurance that the Government take the issue of diabetes very seriously. I assure him that we will continue to hold NHS England to account for the performance of the system against those metrics, as I am sure your Lordships’ House will hold Ministers to account.
I hope this has been a helpful debate, and I will make sure that we get letters to explain any questions I have not fully answered from the noble Lord, Lord Warner. With that, I hope that he will feel able to withdraw the amendment.
My Lords, this has been a helpful short debate, and I am particularly grateful to noble Lords, especially the noble Lords, Lord Lansley and Lord Hunt, and the noble Baroness, Lady Wheeler, for their contributions and for opening this subject up a little.
The purpose of my wording of this amendment—I did not think it was a perfect piece of parliamentary drafting—was mainly to flush out what the Government are going to do on patient choice and provider regimes. We have an answer on the latter. We will not know what is in the provider selection regime regulations until after Parliament has passed this legislation. That does not seem to me to be a particularly satisfactory position to be in, for the reasons that the noble Lord, Lord Lansley, said. So, I strongly encourage the Government to get on to the Department of Health and Social Care officials and speed the process up. Even if they are only draft regulations, they should be made available to your Lordships so that we can see what the Government’s practical intentions are.
I will not go into a defence of the private sector—I do not particularly want to do so—but, in the past, when it has been bought in on NHS contracts, it has brought more professionals to the party. Part of the original contracts for ISTCs made it clear that the private sector could not swipe NHS consultants; it had to find its own staff, who were not working in the NHS, to deliver on those contracts. So, they added to the capacity. I remind Members of this House that the thing about diagnostics, which the noble Baroness, Lady Barker, rightly raised, is that you can use the spare capacity in the private sector at marginal cost, so that you are not paying the full cost you would normally have to pay. So, there are some advantages there, if a Government know what they are doing in their contracting.
Finally, I was not satisfied with the noble Baroness’s answers both in relation to the NAO report and more generally. It is very easy to give me and the House figures for expenditure. I was asking how many patients will actually benefit, because the currency for waiting lists is patient numbers. We want to know how many people will be taken off those waiting lists as a result of the Government’s expenditure—that is the issue I was looking for some enlightenment on.
The background to this is: will I go further on Report? The answer is: I look forward to hearing what the Government say between now and then, but, at the moment, my inclination is to come back and test the opinion of the House. I beg leave to withdraw my amendment.
Amendment 72 withdrawn.
Amendments 73 to 77 not moved.
78: Clause 20, page 17, line 14, at end insert—
“14Z39A Duty to review latest innovations with a view to local commissioning (1) Integrated care boards must review all new—(a) medicines,(b) medical devices, and(c) other health care solutions that may benefit the local population.(2) Integrated care boards must—(a) appoint a dedicated innovation officer to their board, and(b) develop and maintain a system to keep up to date with medicines and devices innovation and review suitability for patient usage, including engagement with the relevant—(i) academic health science network, and(ii) local pharmaceutical committee.”Member’s explanatory statement
This amendment would mandate ICBs to monitor and assess innovation for the benefit of the local population.
I have four amendments in this group; I will speak to each in turn and look forward to hearing what the noble Lord, Lord Sharkey, says on his two amendments.
I thank the noble Lords, Lord Hunt of Kings Heath, Lord Patel and Lord Kakkar, for supporting Amendment 78. It looks at innovation, recognising that it is an ongoing iterative process that every ICB should be aware of to ensure that patients have access to the most efficient and effective healthcare solutions of the day. To that end, is purpose is to oblige integrated care boards to formalise the obligations of the board to horizon-scan for the latest innovations, as approved by regulatory bodies, to cover their population.
This new clause would require the appointment of an “innovation officer”, or potentially identifying an officer to take up that role, and place an obligation on the board to constantly review innovative medicines and devices, as they become available. This is a separate and additional duty to that to promote research.
This amendment is very much supported by the Association of British HealthTech Industries, which has its own chief innovation officer campaign that has been supported by several noble Lords. Essentially, its thinking is that it is at the moment nobody’s job to horizon-scan for new innovations that may bring huge benefit to patients and, therefore, they are often not being prescribed. As we know, the NHS is under pressure and, if no one is responsible for this, it most likely will not happen. I specifically refer to the Academic Health Science Networks—there are 15 across England—as they are spread over the country and provide a good link between research and hospitals.
I turn now to Amendments 81, 96 and 135. Research is critical to the continued treatment of medical conditions in the UK, with our world-leading life sciences sector playing a critical role. However, the system is currently fragmented, and research has struggled to access patients for use in clinical trials. This means that joined-up research to address national health challenges or emergencies is extremely difficult. It is also difficult for research to access patient groups across ICS footprints in order to develop rare and ultra-rare treatments. Personally, I am not entirely clear what the status of clinical trials within the European Union is at this stage; we debated that in earlier legislation and it would be helpful to have an update from the Minister, if possible.
To address these gaps, each ICB should be required, through these amendments, to put in place a research strategy to enable them to proactively engage in or support research into local healthcare issues or challenges and to enable participation in national research projects. Secondly, to ensure operational delivery of this strategy, each ICB should be obliged to consider any request for a local or national clinical trial that benefits the local patient community or supports the national NIHR research programmes. They should then undertake appropriate patient recruitment and obtain the necessary consent. Further, each ICB should be required to publish annually the research it has undertaken in that year, which should be included in an annual report. NHS England should be obliged to collate this information and present it to Parliament.
Amendment 81 in my name would require ICBs to establish a research strategy across healthcare and other connected measures. Amendment 96—for which I am delighted to have the support of the noble Lords, Lord Patel and Lord Kakkar, and I thank them for that support—would require integrated care boards to consider annual requests to engage in clinical trials and offer patients the opportunity to participate. Finally, Amendment 135 would require integrated care boards to publish an account of their research activity and would require the report that the Secretary of State must prepare and lay before Parliament, under Section 247D of the National Health Service Act 2006, to include a section that reproduces and comments on the research activity of all ICBs.
With these few remarks, I beg to move.
My Lords, it is a pleasure to follow and to agree with the noble Baroness, Lady McIntosh. I will cover some of the same ground in my remarks.
I start by declaring my interests as chair of the Association of Medical Research Charities and of the Specialised Healthcare Alliance. The alliance campaigns on behalf of those 3.5 million of us who have rare or complex conditions. The members of the AMRC spend around £1.7 billion a year on medical research, mostly through universities in the United Kingdom. That is more than is spent by the Government via either the Medical Research Council or the National Institute for Health Research.
I will speak to Amendments 79 and 196 in my name and the names of the noble Lords, Lord Kakkar and Lord Patel, and the noble Baroness, Lady Blackwood. It is a privilege to have the support of such extremely distinguished and expert Members, and I am very grateful to them. The amendments also have the support of much of the medical research sector. Both amendments concern research within the NHS. This subject is a long-standing preoccupation of the medical research community, the NHS and the Government.
As long ago as 2011, the Academy of Medical Sciences published an influential paper setting out some key findings, prominent among which was the difficulty in attaining NHS permissions for research. In fact, this was identified as the single greatest barrier to health research. In 2017, the NHS and NIHR published a joint paper called 12 Actions to Support and Apply Research in the NHS. The NHS Long Term Plan, published in 2019, was generally received positively but actually had little to say about research. As your Lordships would expect, the NIHR did have something to say about research in its work of March last year, “Embedding a Research Culture”, which rehearsed the benefits of a research-intensive NHS. Three of the main actions called for were:
“Improving visibility and making research matter to the NHS … Making research more diverse and more relevant to the whole UK … Strengthening public, patient and service user involvement in research.”
These are obviously very important goals, but setting them out as clearly as the NIHR does makes it clear that the NHS’s performance in this vital area really does need improvement.
Also in March last year, the Government published a ministerial paper focused entirely on the delivery of UK clinical research. The paper set out the value of clinical research and our world-leading position. It made the assertion that
“research is the single most important way in which we improve our healthcare—by identifying new means to prevent, diagnose and treat disease.”
It concluded that that meant
“embedding clinical research at the heart of patient care and the NHS, making participation as easy as possible and ensuring all health and care staff feel empowered to support research.”
I strongly agree with both these assessments, and I am very glad to see them as firm policy goals. I welcome the clear and directive language and the signals of intent, which is why I was extremely disappointed to see such a very weak obligation as regards research in the Bill.
New Section 14Z40, inserted by Clause 20 on page 17, sets out what it describes as a duty in respect of research for ICBs. It simply says:
“Each integrated care board must, in the exercise of its functions, promote— (a) research on matters relevant to the health service, and (b) the use in the health service of evidence obtained from research.”
This is essentially the same kind of duty as imposed by the 2012 Act, and it is extraordinarily weak. The word “promote” is not really meaningful. What would satisfy this condition? Mere exhortation would probably qualify. Imposing a duty to actually do research would be much clearer, much simpler and more likely to have an effect. This would also be consistent with the Government’s view of the critical importance set out in the ministerial paper. That is what our Amendment 79 seeks to do. It is a “must actually do something” obligation rather than a “promote the doing of something” obligation. It requires that ICBs must ensure that those eligible organisations for which the ICB is responsible conduct research on matters relevant to improving patient outcomes and healthcare delivery and promote the use in health and care of evidence obtained by research.
The amendment has two additional parts. The first is to impose a requirement for ICBs to co-produce research aims with local place-based partnerships and to ensure diversity of participation. This acknowledges both the benefits and the necessity of place-centred research and close partnership in the production of research aims. The second additional part of our amendment is simply a requirement that the ICB publishes via its annual reports and joint forward plans the steps it has taken or plans to take to deliver clinical research.
Our Amendment 196 is also in this group. It deals with research directly in trusts and foundation trusts. As things stand, Schedule 4(16) of the 2006 Act says only that
“An NHS trust may undertake and commission research and make available staff and provide facilities for research by other persons.”
This is clearly permissive and not directive. Our Amendment 196 would remove this paragraph and replace it with a requirement for both trusts and foundation trusts to actually carry out research, as in Amendment 79. The amendment would also preserve, from the 2006 Act, making available staff and providing facilities for research by other persons.
I strongly believe that both amendments—all parts of them—are in keeping with the ministerial paper, Saving and Improving Lives: The Future of UK Clinical Research Delivery. I hope that the Minister will recognise the cross-party and not adversarial character of our proposals. We really agree with the Government about the paramount importance of research in the NHS—we just need to make it happen. I look forward to the Minister’s reply and to further discussions between now and Report.
The noble Lord, Lord Howarth of Newport, is participating remotely. I invite him to speak now.
My Lords, if, as I hope, the Bill will be amended to establish a quadruple aim for the NHS—the fourth aim being the reduction of health inequalities—then it will follow that we must have systematic research into the origins and remedies of health inequalities. In this connection, we need to understand options for using cultural, natural and community assets within the changing structures of health and social care, in particular at ICS level. Research should lead to better understanding the relationship of such assets to health inequalities, with a view to health systems mobilising those assets in prevention and intervention strategies, particularly to benefit people living with complex needs in deprived areas. The spectrum of research receiving public funding needs to run from laboratory-based clinical research to public health and community-level action research. The system needs to build capacity at that latter end of the spectrum, training and providing funding and opportunity for new cohorts of such researchers.
Let me give a few instances of the kind of down-to-earth research that needs to be funded. How are improvements to well-being, including staff well-being, to be measured, valued and integrated most effectively with policy at ICS level? More research is needed on the cost-effectiveness of community-based programmes. More research is needed on the cost and health benefits of the link worker model in social prescribing and on financial models for integrating community assets into health systems. Social prescribing needs to be underpinned by robust research on what we might call dosage. How much of such activities should be prescribed, and for how long, to bring about measurable behaviour changes and health outcomes? More evidence is required regarding the sustained, longitudinal effects of engaging in non-clinical programmes across specific health conditions such as cancer, stroke, dementias, diabetes and heart disease.
Such needs are being recognised by UKRI and, under its umbrella, the ESRC, the NERC, the MRC and the AHRC. What is also striking is the growing international interest and evidence base for this kind of research, as demonstrated by the World Health Organization scoping review by Daisy Fancourt and Saoirse Finn, entitled What is the Evidence on the Role of the Arts in Improving Health and Well-being?, and the establishment of the WHO Collaborating Centre for Arts & Health, based at University College London. The aims of this centre are to carry out world-class research into how the arts, culture and heritage affect mental and physical health; to work with world-leading researchers in the UK and internationally to develop and improve arts and health policy globally; and to provide training opportunities, toolkits and resources to support development in the field, including facilitating opportunities for early career researchers.
One admirable model is SHAPER, a £2 million research programme funded by Wellcome to assess the implementation of three creative health interventions by embedding them in clinical pathways across King’s Health Partners, bringing together academics in psychiatry and epidemiology with the King’s Centre for Implementation Science, as well as clinicians and researchers across King’s and King’s Health Partners, and three arts organisations, Breathe Arts Health Research, the English National Ballet and Rosetta Life. This programme will explore the barriers and enablers for taking effective interventions to scale and learning from it will inform the spread of creative health interventions in other parts of the country. The interventions include Melodies for Mums, a 10-week singing and music programme for mothers with postnatal depression, which has reached 300 mothers in Lambeth and Southwark.
The National Centre for Creative Health, a charity of which I am chair, is working with Professor Helen Chatterjee of UCL on a UKRI-funded, cross-council research programme, led by the AHRC, to better understand how cultural, natural and community assets can help mitigate health inequalities. The programme will support research in pilot sites across the UK, with a focus on how prevention and intervention strategies can be scaled up from small, locally based approaches to whole communities and systems. As a charity, one of NCCH’s purposes is to seek to ensure that key gaps in research relating to creative health are filled and appropriate skills developed and embedded in healthcare systems, along the lines of what may be envisaged in the Bill and what is spelled out in some of these amendments. Amendments 79 and 196, just introduced by the noble Lord, Lord Sharkey, are particularly valuable in specifying obligations for ICBs and NHS trusts to conduct local research.
I have some questions for the Minister; if he is not able to answer them this afternoon, I would ask him to write to me. To what extent does he intend that the gathering and reporting of data by ICBs should be standardised and how do the Government intend to proceed on this? Will success measurement focus on not just process but outcomes, both near-term and sustained? How will the Government harvest and use the evidence on innovation provided by the work of academic health science networks?
I wonder also whether the Minister could tell us something about the thinking of the National Institute for Health Research, going beyond the helpful remarks of the Baroness, Lady Chisholm, in her response to the last debate on Thursday. I appreciate that its budget, albeit very substantial, is under constant pressure from the insatiable demands of clinical research and that many high-quality research bids have to be turned down. I also appreciate the requirement not to compromise academic standards. However, does the NIHR appreciate the need to fund and develop research methodologies that differ from the time-honoured models such as RCTs and support other types of research, including coproduction methodologies, vital to improving our capacity for both prevention and bringing about a health-creating society?
My Lords, I want to direct a few remarks to the issue of research, in broad support of the speeches made so far. The amendments in this group, taken individually, are generally to be welcomed, not least because they highlight the issues involved. However, taken as a whole, they suggest that there is a need for a more coherent approach, based on the common principles that apply across the whole range of providers and the whole spectrum of health and social care.
The point of principle is that there is a demonstrable association between the provision of high-quality care and participation in high-quality research. Put simply, patient outcomes in services that actively take part in research are better. This does not mean just future improvements in care, diagnosis and so on; the actual care provided alongside the research benefits from involvement in that research. It is reasonable to assume that the same is true of care services; I direct my remarks at healthcare, but I am sure these principles apply equally to those involved in the provision of social care.
Given the principle that research is so important, it is worth making a few additional points. First, research must be an essential element in a system of healthcare, involving both the bodies that deliver healthcare and service users. Hence ICBs need to have a research strategy and not just promote research but take practical steps to facilitate it. In this context, the importance of national research objectives should be emphasised. The involvement of these bodies in research should be more than just one more administrative hoop they have to jump through. It should be part and parcel of their core function, delivering better mental and physical healthcare. They also need to commit to training clinical staff in how they can participate to best effect in research, or at least in the importance of research to clinical care.
Secondly, there is a need to consider a duty on private providers of NHS services to participate in research. Of course, private providers have a duty to support and contribute to the training as well. It is easy for private providers to ignore the need for research, and this reduces the opportunities for those for whom they care.
Thirdly, on Amendment 96, I suggest that we need to go beyond the idea that clinical trials need to be considered by ICBs and other relevant agencies. We could go further and require ICBs to use their best endeavours to encourage and accept reasonable requests to support clinical trials and offer opportunities for patients to take part.
Fourthly, as we have touched on in previous debates in this Committee, it must be emphasised that, when addressing the issue of research, there is a need to refer explicitly to mental as well as physical health.
Finally, all of us should bear in mind the importance of service users being involved in research and of ICBs and other agencies keeping this in mind throughout the process of providing care. This includes the involvement of service users in developing the priorities of research in its design and in overseeing its carrying out. This is vital for making sure that the outcomes can be easily embedded in clinical and care services. It is worth emphasising this in the context of mental health, where most advances in patient involvement have taken place.
My Lords, I thank the noble Baroness, Lady McIntosh of Pickering, and the noble Lord, Lord Sharkey, for the thoughtful way in which they introduced the amendments in this group to which I have added my name. In so doing, I remind noble Lords of three interests: I am chair of the Office for Strategic Coordination of Health Research, chair of the board of trustees of UK Biobank and chair of King’s Health Partners.
As we have heard in this debate, research is not only fundamental to securing the best outcomes for patients being treated in our hospitals and throughout our healthcare system; it is critically important for the sustainability of the healthcare system itself. Numerous reports and strategies have been published over the last 10 years, to the great credit of Her Majesty’s Government, in terms of putting innovation and research at the heart of repeated NHS strategies. It is therefore only right that your Lordships’ House pays particular attention to how securing the opportunity for that research and promoting the opportunities that will flow from it are reflected in the Bill. There is no question but that Her Majesty’s Government are deeply committed to this area, but, as the Bill is currently drafted, there is some anxiety that the provisions and clauses do not provide sufficient emphasis or obligation for the new NHS organisations, the integrated care systems and the integrated care boards—and, indeed, the continuing obligation for NHS trusts—to be actively involved in research.
Now why is this important? At the very least, we know that we need to continue to innovate, be it therapeutic innovation or innovation through devices—or, indeed, innovation of new working practices, pathways of care and delivery—if we are to continue the important advances in outcomes that we have been able to achieve in recent years and decades. As we have heard, research is at the very heart of our ability to improve the experience and clinical outcomes of our patients. Research is also fundamental in improving our ability to prevent disease. We have an obligation in this Bill to promote healthcare services and well-being and to avail ourselves of the substantial opportunities that exist with regard to a more focused prevention agenda. Much of that agenda must inevitably be driven by prospective research, to be conducted across broad and diverse populations on our fellow citizens.
There is the question of sustainability—the fundamental sustainability of the NHS. Here we recognise that, without research and the adoption of innovation resulting from that research, the demographic changes and increasing demands that attend the delivery of healthcare in our country will make the NHS unsustainable in future. Therefore, there is a very deep obligation, beyond what we can do for patients in terms of clinical outcomes, to put at the heart of NHS thinking and strategy, as well as delivery, the delivery of a substantial research agenda. We know that that that research agenda is secured centrally through the substantial commitment of public funds to the National Institute for Health Research, UKRI and Research Councils, which provide funding for research—and, indeed, for other contributions from government departments, including the third sector contribution and the substantial contribution for research provided by the pharma and biotech industries, and associated research opportunities.
All that needs to be directed towards NHS institutions that are ready to receive that substantial commitment to research and conduct in particular those clinical research opportunities which, regrettably, have been subject to variable performance over many years in the NHS. It is for that reason that this Bill must take the opportunity to address that variability in research participation and performance. If we do not achieve that, we are not going to utilise the full potential of the NHS to be able to deliver the benefits that have been so rightly predicted. Most of all, without ensuring a broad research culture across all NHS institutions and organisations, we are going to lose the direct consequences of such a research culture and infrastructure in terms of the fact that patients in research-active institutions have better clinical outcomes.
To move away from those two broad areas—the important impact on patients and the important opportunity to provide the broader research agenda with the innovation that flows from it—there is a third imperative: our capacity to attract and retain staff. As with any facet of manpower planning, it is vital to provide the opportunity for NHS staff members and healthcare professionals to be research-active. It provides a substantial incentive and encouragement and allows for career development, ensuring that we retain colleagues for longer and are able to develop them to make different contributions—all vitally important. If we take this as a whole, it is appropriate that Her Majesty’s Government give some very careful thought to the purpose of these different amendments and how what is being said in your Lordships’ House today might be included in the Bill in such a way to strengthen these research obligations and ensure that NHS organisations deliver on the health agenda.
In finishing, I make one further observation. Beyond the health gain that drives a research strategy applied across the entire NHS, there is a broader wealth gain for society and our economy. It is well recognised that after financial services, the field of life sciences represents one of the most important economic sectors in our country. To fully mobilise that opportunity, we need to ensure that, while its primary objective is to secure high quality, effective and safe care for all patients, every part of the NHS is also mobilising that public investment to ensure that what can be done to promote research and innovation, is being done, so that the second opportunity—driving wealth creation in our country—is also achieved.
I am sorry—the noble Lord, Lord Patel, is here. I meant to say the noble Lord, Lord Bethell. I apologise for my senior moment.
I will begin again. I rise to speak on behalf of my noble friends Lady Blackwood and Lord Bethell, neither of whom is in their place. I should, out of an abundance of caution—particularly given how well I have spoken so far—declare the interests of both my noble friend Lady Blackwood and me, as the present and past chairs of Genomics England.
In speaking to Amendments 79 and 196, we wish to support the noble Lords, Lord Sharkey, Lord Kakkar and Lord Patel, in calling for trusts and integrated care boards to have a duty to conduct research and to report on the steps they have taken to deliver it. We know that there are excellent research-active NHS organisations in the UK, ranging from our acute tertiary university hospitals, such as Oxford, to our district general hospitals, such as Portsmouth.
There are many initiatives to promote research, such as Saving and Improving Lives: The Future of UK Clinical Research Delivery, which sets out a bold and exciting vision. In particular, my noble friends and I await with interest the Find, Recruit and Follow-up service, which plans to use digital tools to identify patients who may be suitable subjects for research. When speaking to patients, one of the refrains that we all hear most often is that they find it hard to find suitable clinical trials, and we welcome any initiative that can make it easier for patients to take part in clinical research.
As well as supporting patients in finding trials, we need to make it as easy as possible for them to participate. In some cases, the pandemic has accelerated a move towards remote monitoring tools—wearables and other devices that allow individuals to participate in trials while reducing the number of visits they have to make to hospitals. We welcome the NIHR remote trial delivery toolkit, which makes recommendations on how some of these positive practices can be continued and so broaden participation and promote patient retention in a beneficial way.
My noble friend Lady Blackwood, as a rare disease patient herself, knows that clinical research is often the only way for patients to get access to innovative treatment. Yet we are saddened to see, in the annual NIHR publication on initiating and delivering clinical research, that some trusts are still not delivering trials every quarter. We continue to see a large disparity in the number of trials being offered in each trust, which leads to a postcode lottery. Those individuals fortunate enough to be under the care of a research-active hospital have an increased chance of being recruited on to a trial, and therefore have better outcomes than patients under the care of less research-active hospitals.
Patients admitted to more research-active hospitals also have more confidence in staff and are better informed about their condition and medication. And as the noble Lord, Lord Davies of Brixton, has said, there is very clear evidence that research-active trusts deliver better outcomes—in part, I am sure, because of their ability to retain and energise staff, as the noble Lord, Lord Kakkar, has mentioned.
The last couple of years, however, have been challenging for the health research community. In 2020, the Association of Medical Research Charities predicted a £320 million shortfall in research spending, forcing many medical research charities to make tough choices about which projects to prioritise. Data also suggests that the UK has been slower to return to pre-pandemic levels of commercial clinical research compared with other European countries.
The Life Sciences Vision sets out the Government’s objective to be a science superpower, but this requires research to be embedded in every part of the NHS, including primary, community and mental health services. That will happen only if NHS organisations, including the new integrated care boards, have a duty to conduct research, as these amendments propose.
In addition, we all know that what gets measured gets done, which is why these amendments place a duty on trusts and ICBs to report the steps that they are taking to deliver clinical research in their annual reports or forward plans. This not only enables progress to be tracked but helps patients understand what research is being done in their area and will encourage NHS organisations to invest in research that meets the needs of their local communities and—
I am sorry to intervene. I am fascinated by everything that is being said but, given the cliché that money does not grow on trees, I am a bit surprised that we have not heard as much as we might have about international collaboration. Is that not a big deal? How would that be measured, as it were, as compared with the issues that the noble Baroness, Lady Harding, has already raised?
I personally believe that international collaboration and engagement in research across all parts of the United Kingdom go hand in hand. It should not be either/or; it is a combination, and we need to do both. The amendments that I am speaking to call for every NHS organisation to participate and become research active.
Finally, and briefly, I urge the Minister to embrace this opportunity to embed what is genuinely cross-party support for clinical research in legislation. We all want to put the UK on the path to being the best place in the world to participate in health research. We will do that, as the noble Lord suggests, by collaborating internationally, but we will address the health inequalities that we have all spoken about over the many days of Committee only if all NHS trusts have a duty to conduct research.
My Lords, I agree with the thrust of all these amendments. Most of the discussion has been about research—encouraging research in clinical trials within NHS trusts and foundation trusts—but I want to speak in support of Amendment 78, in the name of the noble Baroness, Lady McIntosh, which looks at the issue of commissioning and the role of integrated care boards, because I believe that it is just as important to ensure that integrated care boards have in mind the need, through their commissioning policies, to encourage innovation. In our last debate on NICE, last week, we discussed the same issue, which is the fact that the reason NICE exists is that there are many innovative new medicines and treatments coming on stream, many of them developed in the UK, which the health service has found difficulty in adopting more generally.
The noble Baroness’s Amendment 78, about ICBs, is designed to encourage the ICB boards to consider that they have a responsibility in relation to innovations. It also proposes that integrated care boards must appoint a dedicated innovation officer to the board. I do not want to open up the issue raised by my noble friend Lady Thornton as we went into Committee, but we come back to the issue of the composition of ICB boards. She referred to guidance issued by NHS England a few days ago, which is not obtainable in the public domain. It is obtainable through something called “NHS Net”, but the Library has not been able to get hold of it. It is a bit much that advice on the contents of the Bill has been given out which we cannot even see. I hope that, as part of his response to my noble friend Lady Thornton, the Minister will look into that.
On the question, “Why add another postholder to the board of an ICB?”, I point to the Nuffield Trust report, which says that no organisation in the health service at the moment—or very few places—has someone with a direct responsibility for encouraging innovation. The Nuffield Trust thinks that having chief innovation officers with broad oversight could make what it calls a fundamental difference. I refer the noble Lord to research by the ABHI, which is essentially the trade association for medical devices. It showed that fewer than 20 NHS trusts across the UK have a member of their board with explicit responsibility for the uptake of innovative technologies.
Sometimes one must be wary of having a board appointment that may seem to be a token appointment. However, when it comes to commissioning, having someone around the table who is constantly reminding the board that through commissioning we must encourage and invest in innovation, would be very helpful. The slew of amendments tabled by the noble Baroness, Lady McIntosh, is valuable in getting that message across.
My Lords, I am only teasing.
I declare an interest as a fellow of the Royal Society of Edinburgh and of the Academy of Medical Sciences, and as a professor emeritus at the University of Dundee, where I have spent all my life bar the first 18 years. I say this because we have lost something in the United Kingdom. A key strength of our academic clinical departments was a worldwide reputation for conducting health service-related research. We were second to none, and I mean that. We have lost that because we have changed the environment. People who work in clinical academic institutions—our so-called teaching hospitals—no longer have the environment to promote that. It was the duty of those of us who worked in clinical academic departments to grow the next generation of academics. It was important that we were all involved in conducting clinical research that produced innovation, better care for patients and a first-rate, first-class, internationally renowned next generation of academics. We do not have that any more, and anything we can do through this Bill to bring that back would be a major plus.
I will speak to the amendments tabled by the noble Baroness, Lady McIntosh of Pickering, and the noble Lord, Lord Sharkey. Much has been said, excellently, and I will try not to repeat it, but a strengthened research mandate through this Bill could support patients, clinicians, NHS organisations and research. The patient benefits from increased research activity have already been mentioned, but there is a significant variability across the UK in the opportunity for patients to engage in research. A strengthened mandate could support ensuring that all patients can access clinical trials and their associated benefits. Therefore, wider changes are needed to increase the competitiveness of the UK as a destination for research, particularly through the proposed changes to clinical trials legislation, and through increases in Department of Health and Social Care and NIHR funding.
This could include measures to support faster approval timelines and closer multiagency collaborations. Clinical research has clear benefits to patients, as has already been mentioned. NHS trusts with higher levels of research have a higher rating from the CQC and better outcomes, as have already been said. During Covid, the UK has demonstrated its potential with the success of Covid-19 research, with 68 commercial Covid trials launched in the UK in 2020—the third-highest globally, beating the United States and the rest of Europe.
How did we manage to do that? It is because, during the emergency, we set up methodologies that allow patients to be involved in trials more quickly by creating a voluntary registry, where patients themselves volunteer to take part in research. I also note the clinical recovery trials that we set up—some noble Lords might have seen the article in the Times, with Sir Martin Landray suggesting that we follow that process in the future to try to find treatments for other common diseases. If we do that, we will lead globally. The NHS has the capacity to do that, but it now requires the will and the leadership from the centre to drive that. The clinical academics will be up to it—they just want to be given a chance. Let us do that, because we have demonstrated that we can.
However, since Covid, we have begun to drop again. We ranked only fifth in Europe for phase 3 trials in 2020. Across all phases, the UK has seen a decrease in commercial trial volume of 24%—or 34%, excluding Covid-19 research. There are clear economic benefits that we will miss out on—I could give the figures, but I will refrain.
The Clinical Research Network and NIHR supported £2.7 billion of gross value added in research and 47,000 jobs. The loss of commercial research across NHS trusts during the pandemic is estimated to have created a deficit of £447 million because we are slow to restart the clinical research that we had to stop because of the pandemic, while other countries—Germany, the Czech Republic, Slovakia, Hungary et cetera—have accelerated.
For a global organisation, trial placement decisions are based on a holistic set of factors, including study set-up timelines, cost, contracting and recruitment. UK Office for Life Sciences 2019 data shows the UK to be seventh in the average time from the core package being received to the first patient being enrolled—behind the US, Spain, Canada, Australia, Italy and Germany.
Before this debate, I spoke to several companies: Silence Therapeutics, EMIG—the ethical group of companies—Pfizer, AstraZeneca and others. I will mention one company: Pfizer, whose study set-up planning timelines fall behind those of many comparable countries, such as the US, Canada, Australia, Spain et cetera. To achieve its goal in clinical research, the UK must realise the potential of its unique health data. That is the key—we have unique health data.
I will give an example of a company that has produced a small-molecule drug to treat patients who might go into cardiac failure. It needs patients who are at risk of this. We have a health database that is unique in the world and that, through clinicians, can identify patients who might be at risk to enter the clinical trial. No one else has that. It does not counter patient-data legislation because it is done through the clinicians. It could be done through primary or secondary-care clinicians.
I think that I have said enough, but I refer again to Sir Martin Landray, who is known for his Recovery trial and use of dexamethasone for treatment of Covid. He is going to use Covid-style clinical trials by setting up a new company to try to find treatments for other common diseases. I urge the Minister to accept this amendment: it will do more good than most.
My Lords, I shall speak briefly in support of this group of amendments, particularly Amendments 79, 81, 96 and 196, which concern both research and clinical trials. I am grateful to the noble Lords who have put their names to them.
As other noble Lords have noted, the Government have actually recognised the need for integrated care boards to have research among their general duties—but one would be hard pressed to realise from the Bill’s drafting that this was a priority. As the noble Lord, Lord Sharkey, said well, the drafting is weak. We need something much more explicit and action oriented. Frankly, “promote” is a vague term that can mean anything or nothing. We need action-oriented language of a kind that puts the NHS and the resources that this country has right at the centre of medical research.
We need an amendment of the type that my noble friend Lady McIntosh of Pickering has put down to give us a national research strategy and join up the national and local levels in achieving it. The noble Lord, Lord Kakkar, has given us many reasons why we need to move on the whole subject of research and make it central to the National Health Service’s mission. We need something that is explicit in charging the NHS to conduct research and enable relevant bodies to do so as well. The results should be exploited in healthcare. Linking research to local needs will also increase their relevance, and the adoption of these results and the obligation to report on them will ensure that things really happen.
I could not find in the drafting any reference to the need to do clinical trials. Surely this is a central element in research and could be extraordinarily advantageous to the UK. As the noble Lord, Lord Patel, has just said, the NHS has a database that is unparalleled in the world. It provides us with an extraordinary advantage. I recall that when I was on the Science and Technology Committee, we heard considerable evidence about the barriers that were put in the way by rather pettifogging EU regulations. I recall the desire, when free of these, to be able to conduct clinical trials. I am aware that some people argue that the UK market is too small, but, with our database, that is not the case—and we can ensure that we have co-operation from abroad.
It is very important that this becomes a central element in our research programmes. It puts us on the map internationally, and it ensures that the NHS, which, after all, is a great consumer of the public expenditure in this country, is also part of wealth creation. That should be part of the result of the research that it conducts.
I do not think that the Government disagree with the thrust of the thinking here, but I very much hope that they will agree that the Bill’s drafting, as it exists at the moment, is inadequate. I hope that, when my noble friend comes to reply, he accepts that the language on both of these elements needs strengthening, giving a central role to research and clinical trials in the NHS.
My Lords, I am grateful to noble Lords for putting forward these amendments, all of which seek to strengthen the Bill and build on what the noble Baroness, Lady McIntosh, opened with: the need for clear lines of responsibility and for a joined-up strategy—in other words, for us to get to the point that we are looking for.
My noble friend Lord Hunt spoke of the embodiment, perhaps, of that through a chief innovation officer, who could be a reminder—not on their own—of the need to build in research and innovation as core throughout commissioning. I am sure that the Minister has heard that this debate is a cry for us to embed in the Bill and in our NHS not just a requirement for but a delivery of research and innovation to the appropriate standard to serve the country. It will not just happen on its own.
We have seen significant variation of opportunity for patients to engage in research and disparities in participation reported on geographic and socioeconomic lines, by ethnic origin and across different disease areas. This is due to the fact that the NHS has been unable to prioritise resourcing and delivery of research, which has been a particular feature over the past decade.
In the Bill, we have a major opportunity to embed a research-active culture—words used by the noble Baroness, Lady Harding—within the NHS which could build on the response to Covid-19, which the noble Lord, Lord Patel, emphasised. That response saw more NHS sites, staff and patients engage in research than ever before. Let us not waste this opportunity.
The Bill offers little different to the Health and Social Care Act 2012, which also did not and does not mandate clinical research activity, stating just a duty for clinical commissioning groups “to promote” research. Your Lordships will notice the similarity in wording in the current Bill. The noble Lord, Lord Sharkey, is quite right, as are other noble Lords, to speak of the weakness of just using the words “to promote”. This set of amendments is about how we make it actually happen. The amendments are about mandating integrated care boards to conduct research and to monitor and assess innovation, because without that, it will just not happen.
Legislation is indeed a critical element, but it is important to stress that it must be accompanied by the necessary infrastructure: for example, through staffing levels—to which we will return in our next debate—research capability, digital resources and tools and access to services, as well as efficient trial approval processes, the ability reliably to recruit patients, the offering of guidance and, of course, dedicated staff time for research. All of those will make the legislation actually mean something.
As well as a strengthened legislative mandate which moves beyond the current duty simply to promote research, it would support patients, clinicians and NHS organisations across the country to have equal access to the benefits brought about by research participation. This will be better for patients, give greater staff satisfaction and deliver economic benefits not just for the NHS but for the broader economy. The noble Lord, Lord Kakkar, talked about the life sciences being a major player as a contributor to our economic well-being and prosperity in this country—something also emphasised by my noble friend Lord Davies.
Such a mandate would also ensure support for levelling up and make it possible to address health inequalities. This in turn would support the ambition set out in the Government’s clinical research vision: to make access and participation in research as easy as possible for everyone across the UK, including those in rural, diverse and underserved populations. I hope the Minister will take the opportunity to reflect on the points made in this debate, because this group of amendments provides an opportunity to strengthen the Bill to actually deliver.
Like many of the debates on this Bill in Committee, this has been a fascinating one. It has been really interesting to hear from experts who themselves have engaged in clinical research. I start by thanking my noble friends Lady McIntosh of Pickering and Lady Blackwood and the noble Lords, Lord Sharkey and Lord Kakkar, for bringing this debate before the Committee today. I also thank the noble Lord, Lord Howarth, for his points about the arts and social prescribing.
Before I turn to the amendments, perhaps I could make two personal reflections. One is from my early academic career as a postdoctoral research fellow. I saw the benefit of taking the results of my research directly into my teaching. It made the courses more dynamic—it was not just a repeat of last year’s slides for this year’s students—and it showed what progress we were making in that field of research.
Secondly, during my appointment as the Minister for Technology, Innovation and Life Sciences, it has been really exciting to see the level of research and innovation across this country, not only in the golden triangle that people talk about—London, Oxford and Cambridge—but throughout the country. It is evidence-led, research-led and really interesting, positioning the UK as a leading place for research and a hub for life sciences. We have looked at where our strengths are. One example is clinical trials. A number of companies say to us, “What is really interesting about the UK is that, especially with social care joined up, we will have data on patients literally from cradle to grave throughout their life”. But there are also all the different pathways and some of the exciting stuff we are doing with Genomics England, which opens up whole new possibilities.
In our previous debate, we heard from the noble Lord, Lord Rennard, about type 1 diabetics and how the technology is improving quickly. When I speak to relatives and friends who are type 1 diabetics, they are excited by the advances being made, which gives them greater confidence that they can lead as near as possible a long and healthy life.
Let me start by addressing Amendment 78, on integrated care boards reviewing all innovations. Although I appreciate the intention behind the amendment, for reasons that I will explain it is unclear what additional benefit such a review would produce. The National Institute for Health and Care Excellence already plays an important role in ensuring that patients have access to promising new innovations by recommending whether health technologies represent a clinically and cost-effective use of NHS resources. Where NICE so recommends, NHS commissioners are under statutory obligations to fund the technology. I note the previous debate on NICE and the points made by the noble Lord, Lord Hunt, but we expect that this requirement will carry over to integrated care boards.
On appointing a dedicated innovation officer and developing and maintaining a system to keep up to date with innovations on boards, this is part of the overall debate on how much you mandate at the ICB level, and I am sure that a number of noble Lords will recognise how many requests there have been to mandate particular places on the ICBs. I suggest that we consider that in the round.
The Accelerated Access Collaborative, the umbrella organisation overseeing health innovation and its ecosystem, will work with NHS partners to look to embed research and innovation within the new statutory ICBs. For example, in their proposed job descriptions, there is a clear requirement for ICB chief executives and chairs to foster a culture of innovation. I have seen a lot of such innovation in many places.
We also have existing reporting tools to monitor the use of innovative medicines and medicinal products. This includes NHS Digital’s innovation scorecard and the AAC scorecard. The AAC is also scoping the development of an innovation metric to help to identify and address unwarranted variation.
On Amendment 79, I share the noble Lord’s intention that the NHS should be research active, that research participation is diverse and research needs are met. The existing research duty in the Bill requires each ICB to promote research on matters relevant to the health service and the use in the health service of evidence obtained from that research. The existing research duty in the Bill is broad and wide-ranging, encompassing actions including facilitating and enabling research, such as through their commissioning functions. I am concerned that the amendment may narrow the research duty to a small number of actions which would not necessarily capture the existing range of activity.
Proposed new paragraph (a) in the amendment would also apply to
“those eligible organisations for which the integrated care board is responsible”.
Although ICBs will be able to influence and affect organisations through their functions, they are not directly responsible for any organisation. Rather than directly funding or conducting research, ICBs will primarily facilitate and enable research. But where it is appropriate for an ICB itself to play a more direct role in research, it will have the power to commission and conduct research, just as CCGs do currently.
A requirement for ICBs to
“co-produce with place-based partnerships research aims to meet the needs of their local communities and ensure diversity of participation”,
risks replicating the requirement for integrated care partnerships to prepare an integrated care strategy setting out how the “assessed needs” of their areas, which can include research needs, are to be met by the functions of the ICBs and others.
The Government are committed to diverse patient participation in research. I am sure that many noble Lords are aware of data, particularly for example in the area of artificial intelligence—as we know, it is not really intelligence but analysing large datasets to look at patterns and help the decision-making of clinicians and others. There has been a lack of diversity in data; we have seen racial bias, for example, in recruitment and college admissions. It is important that we do not repeat that in this country, especially since we do have a diverse population, and that we ensure that we have a diverse a research set as possible. I know from speaking to my noble friend Lady Blackwood that Genomics England is concerned about this and is looking to make sure that its datasets are as diverse as possible, especially with the increased use of AI.
There are requirements for researchers on equality, diversity and inclusion. These have been strengthened in research funded by the Department of Health and Social Care through the NIHR. Researchers are now expected to demonstrate how they will ensure that recruitment is inclusive and representative of the population. The Bill also requires that the forward plan must set out how the ICB and others propose to exercise their functions and the annual report must report on how it has discharged these functions. This must include how ICBs will plan and promote research and deliver clinical research.
Amendment 81 would mandate ICBs to develop a research strategy for patient benefit each year, following engagement with the NIHR and all relevant regional and national health and care organisations. However, ICBs already have a duty to promote research, and the power to commission and conduct research, so they will already need to plan their research activity to be able to discharge these functions. Where they are aware of local research needs, this should be addressed when they plan their activity. As a result, we do not think that it would add value to require ICBs to develop a separate strategy.
On the requirement for ICBs to engage with all relevant regional and national health and care research organisations, we expect ICBs to collaborate with relevant bodies where necessary without requiring this through primary legislation. Integrated care partnerships—ICPs—as joint committees of ICBs, local authorities and others, also have a huge role to play here. They must prepare an integrated care strategy setting out how the “assessed needs” of an area are to be met by the functions of the ICBs and others. Local research need could fall under an “assessed need” as it is capable of being met by ICBs and could be affected by the actions of the responsible local authority, so would need to be addressed by the integrated care strategy without the need for a separate strategy relating only to research.
The Government, through the NIHR and UK Research and Innovation funding, provide support to organisations to undertake research and develop strategies. This includes providing funding directly to meet support costs so that the NHS can deliver non-commercial research, through the NIHR Clinical Research Network, for example.
I now turn to Amendment 96, which would create a duty for ICBs to consider requests to engage in clinical trials and would mandate that participation to any eligible patient within their area. I understand and share the desire of your Lordships’ House for ICBs to take research seriously. A research-active NHS culture brings benefits for patients, staff, the NHS and the wider economy. I am keen that we harness those benefits to build on the progress made by CCGs as well as the research that I have become aware of since becoming the Minister for Technology, Innovation and Life Sciences.
In wanting to give ICBs the flexibility to develop the processes and structures that work most effectively, we feel that a statutory duty for ICBs to consider requests would be overly prescriptive. Also, a duty only to consider requests is likely to have little effect in practice. We expect ICBs to consider requests put to them without needing this to be in primary legislation. While ICBs will play a role in enabling and facilitating research in the NHS, in many instances we would expect that it would be for trusts rather than ICBs to consider participation in individual clinical trials.
We believe that a more effective way to broaden participation in these trials is to ensure adequate funding and infrastructure to support research in all parts of the country. The Government do this through NIHR funding and infrastructure; 100% of NHS Trusts in England are research active. This is due to support such as the NIHR Clinical Research Network, which meets many costs, including of equipment.
I turn to some of the questions on diverse trial participation. As noble Lords have alluded to, the Government published in March last year the UK vision for clinical research delivery. This includes provisions on diversity. It supports diversity in child participants through such initiatives as INCLUDE, funded by the NIHR. Other examples include partnership with the centre for black and minority ethnic health. In Leicester, the NIHR is addressing low participation by black, Asian and minority ethnic communities in research, in particular Covid-19 studies. These are just a couple of examples.
I turn now to Amendment 135, which aims to ensure that the ICB’s annual report covers research activity. In this Bill, ICBs have a broad duty to promote research and the evidence obtained from research, and they will be able to fulfil this duty by exercising their power to commission and conduct research. But ICBs will also be uniquely positioned to facilitate and enable research in ways broader than direct activity, such as through the exercise of their commissioning function. For example, ICBs could promote research by commissioning services from providers that are research active or are proactive in facilitating research—a much broader range of research, as the noble Lord, Lord Howarth, said.
The Bill’s drafting on the ICB’s annual report is deliberately broad and permissive, and sets out that an ICB must prepare the annual report
“on how it has discharged its functions”.
This already includes research activity, as well as broader actions to promote research. The Bill provides that NHS England may give directions to ICBs as to the form and content of an annual report.
On a requirement for an ICB’s annual report to cover the progress of applications considered by the relevant research ethics committee, I reassure my noble friend that the Health Research Authority, which administers research ethics committees, already publishes performance data on its website regarding the time taken to approve such studies. The HRA’s transparency strategy also asks research sponsors to include a plain-language summary of their findings in their final report; these can be found on the HRA’s website.
The requirement that the Secretary of State’s annual report on the performance of the health service should cover the research activity that ICBs have included in their annual report is something that we consider unnecessary as it would duplicate the performance assessment regime already provided for in the Bill.
I end my remarks on this group with Amendment 196. I understand the intention behind this amendment: making sure that research is taken seriously by NHS trusts is something that I think all noble Lords would agree on. However, we consider that an amendment to require trusts and foundation trusts to conduct research is unnecessary, since 100% of acute NHS trusts and foundation trusts in England are already active. The amendment would impose a duty for trusts to promote the use in health and care of evidence obtained from research. In fact, there is already a range of legislative and non-legislative means by which providers are required to provide services that are informed by the evidence from research. The equivalent duty already applies to CCGs, and will do so for ICBs.
As regards the requirement for NHS trusts to
“co-produce with place-based partnerships research aims to meet the needs of their local communities and ensure diversity of participation”,
I have already referred to a number of the requirements for diversity. On the requirement for NHS trusts and foundation trusts to publish, via their annual report, the steps they have taken to deliver clinical research, the NHS Act 2006 already requires this, and trusts must send their reports to the Secretary of State. NHS foundation trusts can similarly already report their research activity through their annual reports, which they are required to make publicly available.
The Government do not therefore believe that it is necessary to require on the face of legislation that trusts set out their clinical research plans in their joint forward plans. This is because the existing requirements in the Bill are deliberately broad. Having said all this, I have heard from a number of clinical research experts. Although the Government believe this, some research experts in this Chamber believe that it should be in the Bill. It is obvious, therefore, that further discussion is needed before Report so that we can consider this in the round. In that spirit, I thank all noble Lords for this helpful debate, which has been very informative, and ask noble Lords not to press their amendments.
My Lords, I am grateful to all who have contributed to what has been an excellent debate. I welcome my noble friend’s offer to have further discussions, which I am sure will be taken up actively by all those concerned.
However, there seems to be a bit of a mismatch between my noble friend’s reply and the very real concerns expressed across the House, including by the noble Baroness, Lady Merron, in summing up. The noble Lord, Lord Kakkar, said that there was insufficient emphasis and obligation for integration, and that the whole country would benefit from wealth creation—a point well made by my noble friend Lady Neville-Jones as well.
I was very moved by the reference of the noble Lord, Lord Patel, to the loss of status and standing of teaching hospitals. My father, a GP, always used to say that if you want something done, have it done in a teaching hospital. My late uncle was a surgeon at the Royal Infirmary, where his students rather fondly called him “Mack the Knife”—I hope for positive reasons, because he used it skilfully, but unfortunately it is too late to ask.
We need to press my noble friend further on strengthening the obligation and making it much firmer in the Bill. Is he prepared to move in that direction? I would like to say how proud I am to be British and living in a country where we have such a strong record on research and the data available. My noble friend the Minister did not respond on where we are with clinical trials—my noble friend Lady Neville-Jones and I particularly asked him about that—and I would be very grateful if he could write to me separately. On the basis that we can have further discussions on this, I beg leave to withdraw my amendment at this stage.
Amendment 78 withdrawn.
Amendments 79 to 82 not moved.
We now come to the group beginning with Amendment 83. The noble Baronesses, Lady Brinton and Lady Masham of Ilton, will be taking part remotely.
83: Clause 20, page 17, line 25, at end insert “and to ensure the availability of sufficient well-trained staff to provide safe staffing levels.”
Member’s explanatory statement
This amendment draws the attention of the integrated care board to the need to ensure sufficient well-trained staff to comply with safe staffing levels.
My Lords, in moving Amendment 83 in my name, I want to speak to Amendment 86, also in my name, and to support Amendments 146, 170 and 171.
Everybody taking part in these debates, including the Ministers, would acknowledge the central importance of the staff of the NHS and social care, at every level, and their training, well-being and retention. However, it was clear from the evidence on the workforce to the committee and in debates in the House in another place that there is broad concern that planning for the provision of sufficient of the right staff in all areas has not been good enough. Given how long it takes to train a doctor, an allied health professional or a nurse, excellent forward planning is essential. Proposals were made in another place to improve that in the future but, unfortunately, the Government would accept only a mandated review every five years. This group of amendments is this House’s opportunity to try again, and I hope the Minister will be able to help us.
These amendments show that, in the opinion of noble Lords, the planning of health, public health and care staff must be based on an accurate, independently verified understanding of both the current situation and, as well as can be predicted, future need. Because the political responsibility lies with the Secretary of State, this information collection and planning must exist at the very top, as well as at NHS England and the ICS commissioning level. Clause 35 refers only to the workforce needs of health services, but Amendment 170 lays down detail on what the Secretary of State must do to fulfil this responsibility, not just for health but for public health and social care, since they are so interlinked. We look forward to the White Paper and legislation on social care and hope that workforce issues will be well covered in them, but we need to address it now, in this Bill, even though it would have been better to hear the Government’s proposals on social care first. Amendment 146 says what must be done at ICS level. Crucially, both amendments require appropriate consultation. But there is something I would like to add, and that is where my Amendments 83 and 86 come in.
Every hospital trust and primary care setting has done the work to identify and agree the safe staffing levels of each type and seniority of staff in each setting. This is based on an understanding of the local context and of the knowledge and skills needed for patient safety to deliver each treatment, and an assessment of how many patients can safely be looked after by each member of staff. This varies enormously from setting to setting—from a whole team of staff to each patient in operating theatres, to one-to-one in ICUs and premature baby units, and to several patients to one member of staff in less acute areas.
During the pandemic, we have seen these levels necessarily abandoned, with, for example, one ICU nurse being asked to care for two or even three patients at the peak. This has been an unusual crisis situation and services have had to be flexible, moving staff from one department to another, always, I hope, under the supervision of a staff member with the correct speciality. Hospitals have helped each other and ambulances have been diverted when no bed could be found for patients coming into A&E. That has been the advantage of having a National Health Service.
It has been very difficult for staff, and many have quit their jobs. We started the pandemic with tens of thousands of doctor and nurse vacancies, and the BMA has calculated that we currently have a shortfall of 50,000 full-time equivalent doctors—more than the number of unfilled posts. Our doctor-patient ratio is 25 years behind that of similar OECD countries. In the UK, before the pandemic, there was already a shortage of around 50,000 nurses, and still the healthcare system is nowhere near bridging that gap. In December 2020, a report by the Health Foundation, Building the NHS Nursing Workforce in England, said that the Government will need to exceed their target of 50,000 new nurses in England by 2024-25 if they want the NHS to fully recover from the coronavirus pandemic.
In January 2021, a survey by Nursing Times indicated that 80% of nurses feel that patient safety is being compromised due to this severe staff shortage, which is why my amendments focus on safe staffing levels. While there has been a good increase in the number of nursing students starting courses during 2020, this will not alleviate the issue of a lack of qualified nurses now or in the medium term. There are particular shortages among mental health and cancer support nurses. Cancer Research has also told us that one in 10 cancer diagnostic posts in England is vacant, which threatens the Government’s cancer target. There are also considerable shortages in other allied professions.
We have also seen a reduction in the number of in-patient beds in the last 10 years and bed occupancy rates well in excess of the recommended percentage. Even before the pandemic, some hospitals had no available beds at all during the winter period, leading to nearly every winter period being labelled a crisis. All this is because of the perennial failure to train enough staff.
Despite the increased use of technology, health and care continue to be people businesses, but there has not been enough effective planning to provide the workforce needed, not just for normal services but to provide the resilience needed for the winter and for future pandemics. This has partly been due to “leaky bucket” syndrome—the failure to retain staff because of the pressure and, in some cases, pay or pension issues. That must change. Health Education England is now to be incorporated into NHS England, and the Bill and the forthcoming social care legislation are opportunities to start again. We have one and a half million care workers, with high turnover. In order to improve retention, good training and a career path are needed.
I turn, however, to the detail of my amendments. Included in the duties of the new ICBs is, as set out in Clause 20, in new Section 14Z41, a duty to promote education and training. My Amendment 83 adds to that duty that it should train enough of the right staff to reach safe staffing levels in all areas. My Amendment 86 adds to new Section 14Z42, which covers the duty to promote integration, a duty to improve the ability of NHS and care staff to carry out their duties within safe staffing levels.
The latter amendment recognises the risk to staff themselves as well as patients when they are forced to work with fewer than the prescribed safe number of colleagues, or to extend their shift by many hours because there is nobody to take over. It is a risk to their physical and mental health and it certainly does not help the ability of student nurses and doctors to learn from their senior colleagues when they do not have enough time to breathe. It also causes burnout, leading to significant numbers of doctors and nurses considering leaving the profession or reducing their hours. Some 32% of respondents to the BMA’s April 2021 Covid-19 tracker survey said that they were now more likely to take early retirement, while half reported being more likely to reduce their hours.
I believe that safe staffing levels are part of the duty of care that employers owe to their employees in the health service. However, the Nuffield Trust, Health Foundation and King’s Fund have estimated that, by 2030, the gap between supply of and demand for staff employed by NHS providers in England could reach almost 350,000 full-time equivalent posts if nothing is done. Worryingly, that was based on pre-pandemic calculations. Overcoming unsafe staffing levels is an essential measure to ensure patient safety and to boost the well-being, morale and productivity of staff and, therefore, their retention. The Bill is an opportunity for the Government to take sustainable action to alleviate issues relating to workforce supply and demand in England.
The duties proposed in Amendments 146, 170 and 171 would be welcome, and I support them, but they are not enough. I think that safe staffing should be specifically mentioned among the duties of the ICB, and that is where my amendments would put it. I beg to move.
My Lords, we have two noble Baronesses taking part remotely. I first call the noble Baroness, Lady Brinton.
My Lords, the present Health Minister and his predecessors for a number of years—far too many years, frankly—should not be surprised by these amendments, all of which cover the issue of workforce planning. Often, Ministers’ words and aspirations have been supportive but the reality is that, without proper long-term workforce planning, the NHS and our social care sectors will struggle to be able to plan for the medium term, let alone the short term.
My noble friend Lady Walmsley introduced this group by saying what is needed in workforce planning and why, and I support her brief but critical amendment to ensure patient safety. The other amendments in this group set out the how: whether the workforce planning reports or clinical and healthcare training needs in Amendment 171, the duty on the Secretary of State in Amendment 173, the report on parity of pay in Amendment 174 or the important Amendment 214 from the noble Baroness, Lady Finlay, on workforce boards. I am looking forward to hearing the expert contributions to follow on them from the noble Lord, Lord Stevens, and many other noble Lords, and I hope that the Minister will take note of how the lack of effective workforce planning is hobbling the provision of health and care services in England.
I will focus on Amendment 170 from the noble Baroness, Lady Cumberlege, which I have signed, which sets out the reporting structures for appropriate long-term planning, addressing future workforce supply over the next five, 10 and 20 years, along with who should be consulted and, importantly, that independent assessors should confirm that the data used is correct. We need to remember that, in the election in 2019, the Prime Minister promised 6,000 more GPs by 2024 and, before him, his predecessor Theresa May had promised an extra 5,000 GPs by 2020. Both were setting themselves up to fail, because it takes five to seven years to recruit and train a GP and another two or three years to provide the extra staff on clinical undergraduate and postgraduate courses to teach them. It is worth noting that the full-time equivalent number of GPs in 2015 was 42,961, which had dropped—not increased—to 35,991 last year. That is a drop of around 15%, and evidence of the burnout and drop-out that my noble friend Lady Walmsley referred to earlier.
Workforce planning must look beyond the traditional doctor and nurse workforce numbers that appear in election manifestos. We know that our healthcare practices are changing, with nurse practitioners, specialist physios, occupational therapists, radiographers and many others all picking up tasks formerly carried out by doctors. With in-patient stays reducing in time thanks to advances in surgery and new treatments, our health and social care system needs to develop new pathways in community deliveries. Without a specialist workforce plan for community deliveries, it will also fail.
The fundamental problem here is, I presume, the cost of clinical courses. Ministers have chosen in the past to rely on bringing qualified healthcare staff in from abroad, especially from low and middle-income countries. This is morally wrong. I am really grateful for the correspondence from Professor Rachel Jenkins, who rightly reminds us why the NHS’s constant use of clinicians and healthcare professionals from lower and middle-income countries, rather than increasing the university and training places for our own home-grown health professionals, is so damaging:
“The heart of the problem is the sheer scale of loss of health staff from low and middle income countries (LMIC) to high income countries, especially to the UK, which has 30% of its doctors recruited from and trained by low and middle income countries, approaching double the OECD average of recruitment from LMIC, and with the situation escalating fast.”
Around 20 years ago, when I was a trustee of Christian Blind Mission, a global disability charity, I saw the consequences of this in practice. CBM worked with the exceptional surgeon Steve Mannion, who provides innovative club-foot surgery and treatment and trains Malawian medical students and doctors in his ground-breaking surgical practices. In 2003, along with local surgeons across Africa, he helped to set up COSECSA, a surgical college to cover central, eastern and southern Africa. He did this because, as he said in 2003, he was the only orthopaedic surgeon for the central and northern regions of Malawi, a catchment population of 6 million to 7 million people. He was clear that this was caused by countries like the UK offering attractive posts in our hospitals, which had catastrophic consequences on medical services in their own countries. In 2003, there were more Malawian surgeons in Manchester than in Malawi.
Because of the lack of workforce planning and funding in place to train those needed for our NHS, many of our hospitals have had to rely on this willing, responsible and committed cohort of professionals from across the world. We are still depriving Africa of surgeons and countries such as the Philippines of nurses, and it is not good enough. My local hospital, Watford General, has a good scheme by which nurses from the Philippines come for a specific time only, and return home with not just experience but further qualifications under their belts.
There is a place for this type of arrangement, but it must not be at the cost of draining the skills from lower-income and middle-income countries and should not be a replacement for the responsibility we bear to ensure that we have the ability to train our own local workforce. I am really grateful to Professor Jenkins for her timely letter. She also pointed out that the ratios of doctors and nurses in lower-income and middle-income countries are still sometimes a third of the numbers we have in more developed countries.
I return to the principles behind the amendments in this group. The lack of proper and effective long-term workforce planning exacerbates many of the problems in our NHS and social care sector. This Bill and these amendments give us the right number of staff that we need to be able to do this, but, without any workforce planning, it will be entirely hit and miss. We need resilience. We cannot continue to lose staff because of the pressure we are putting them under. We must not have a service that becomes unsafe because staff step up to do extra shifts, over and above, when they are extremely tired.
We have to have clear career pathways linked to workforce planning, not just in the NHS but in social care. We cannot have the position we have at the moment, where social care is being denuded of nurses because they are all going to the NHS, which can offer them more pay. Above all, we need a key tool for the design, funding and delivery of health and care services in England in future. These amendments, especially Amendment 170, set out how we can do that. I look forward to the Minister’s response.
My Lords, we have one more noble Baroness taking part remotely. I invite the noble Baroness, Lady Masham of Ilton, to make her comments.
My Lords, I am very supportive of this group of amendments. There cannot be a safe, effective National Health Service without an adequate, well-trained workforce in hospitals, in care homes and for people who need care in their own homes, as well as adequate GPs and community staff.
At this time, it is more difficult than ever to recruit, as so many nurses and carers left to go back to Europe and the world has been struck by the coronavirus. Many people are off sick with the virus or isolating, and some are tired with stress and overwork. It is not helped when the relations and partners of patients have not been allowed in to help disabled and elderly patients in hospitals. They can help with feeding and giving patients extra help and support, which staff do not have the time to do.
The Royal College of Nursing says that the Bill gives
“no assurance that the system is recruiting and training enough staff to sustainably deliver health and care services.”
As has been said, there should be forward planning for the workforce. For example, the biggest barrier to improving early diagnosis of bowel cancer is long-standing staff shortages in endoscopy, pathology services and gastroenterology, with 43% of advertised posts not being filled. This is really serious. With so many posts across the country not being filled, a variety of specialties are so badly needed. There must be more training opportunities. Without adequate training, there will be no hope of filling the unfilled posts.
It would be very welcome if the Government brought some amendments on Report to help make the recruitment of staff, who are so desperately needed, more successful. Without enough staff, all the important things your Lordships have been discussing today, such as innovation and research, will be unachievable. A thriving workforce is absolutely essential.
My Lords, manpower planning requires a bit of definition. In my role at the TUC over many years, one of my functions was to look after all the sectoral committees. The most assiduously attended was the health services committee. As we all know, there is an enormous number of specialities in the health service.
When it comes to manpower planning, why did people not press the right button? I am afraid that there is no button to press. In 1947 Aneurin Bevan found that with the British Medical Association there was no wish or desire on the part of the doctors to be part of a structure where a button could be pressed—as might be true in a great corporation—to make sure that the plan for manpower was implemented. As we all know—I will be corrected by someone in this Committee if I have got it wrong—GPs are not appointed by the National Health Service in the way you would appoint somebody to be in charge of an oil refinery in the oil industry or whatever.
It would be useful if the Minister—and I have given notice of a question along these lines—could say what the subjects of the workforce strategy in the Bill would be. How would it be funded? What would be the timescale for introducing it? How often would it be updated? The analysis would have to include such questions as reliance on locums; anecdotally, they can prove very expensive. Will there be targets and associated timescales for the reductions in vacancies?
All of this is easier said than done. I think the remark can legitimately be made that money does not grow on trees, so how are we going to proceed on this? I do not think that everybody who advocates manpower planning is totally naive. Jeremy Hunt in the other place advocated something very much along the lines of what we are talking about now. The focus of the question was on whether five years, 10 years or some other number of years was far too long. There should be reviews every two years or on some shorter timescale.
I confess that, if I were the Minister, I would say, “You’re begging the question of whether we know what we’re talking about when we talk about manpower planning”. So I would be glad if the Minister, in giving some thought to this debate, would care to write to noble Lords—not a White Paper or anything like that—to answer specifically how this thing would work. It is an excellent initiative, and I very much welcome the fact that there is a clause in the Bill providing for this manpower planning.
Edward Argar, for the Government, said that substantial work was ongoing, and referred to a 15-year strategic framework for the health and social care workforce, so the beginnings of creative thinking in this area have gone some way. I congratulate the Government on that. I am afraid, however, that until we get Ministers to be a bit more explicit about what we are talking about, and how the workforce plan will work, this will be a missed opportunity.
In conclusion, I acknowledge that there are a number of sacred cows in this area—and unfortunately, many of those sacred cows are incompatible with each other. It would be useful if the Minister acknowledged that we are asking the right questions. That, obviously, is the necessary precondition to finding the right answers.
My Lords, I shall speak to Amendment 170, in my name. I thank the noble Lord, Lord Stevens of Birmingham, who supported my amendment, the noble Lord, Lord Hunt of Kings Heath—I do not know whether he is coming back—and the noble Baroness, Lady Brinton, who has already spoken. I thank the noble Baroness for speaking to the amendments in her usual comprehensive and thorough way. It was interesting that she talked about Malawi and the Philippines, and the issue of local training, which is so important.
We have all applauded health and care workers, both on our own doorsteps and when we meet them, on or off their job. Omicron has put them under huge pressure yet again, but despite that—despite isolating or testing positive—we know that they will cope. The NHS will cope.
The NHS is a public service, which means the service works for the people. That is its sole purpose. To achieve that, normal service must resume as soon as possible. The public have been understanding: they understand that there is a crisis, and that normal service cannot be delivered right now. There can be no doubt that Covid and its variants are a crisis for health and care. But Covid is a crisis atop another crisis, a deeper malignancy, which constrains and threatens the NHS—and, of course, the care sector; we must think of the two together—with or without Covid. I speak of the workforce crisis, now considered by experts, and by people in the service and outside it, the single greatest problem that the service now faces.
Numbers can be used to make any argument stand up, even a spurious one. But in the case of our health and care workforce crisis, the numbers are real, stark and heading in the wrong direction. Two years ago, before the pandemic, the average number of vacancies in adult social care was 112,000; the average number of vacancies in the NHS was 101,000. It is no secret that Covid is making a very bad situation worse. Internal NHS figures showing total absences across acute, mental health and community trusts nationally hit almost 120,000 on Wednesday 5 January. NHS staff absence figures are published weekly over the winter. The reported figure for staff absences, published last Thursday, 13 January, show that a weekly average of almost 89,000 hospital staff in England were absent, with the highest one-day peak for this winter being over 94,000. This is piling pressure upon pressure.
That tells us that we have a serious problem here and now—and, as the noble Baronesses, Lady Masham and Lady Brinton, said, it takes a long time to train skilled health and care staff. We need to act now if we want to feel the benefit in future. According to the Royal College of Physicians, nearly 48%—nearly half—of advertised consultant posts went unfilled in 2020, mostly due, sadly, to a lack of any applicants. The noble Baroness, Lady Finlay, mentioned this in a previous debate.
There are nearly 40,000 full-time equivalent nurse vacancies in the NHS in England. That is a vacancy rate of more than 10%. The Royal College of Nursing expects 52,000 nurses to retire in the next few years. Nearly 7% of roles in adult social care were vacant in 2020-21. It is estimated that we are 50,000 doctors short, and in total the Health Foundation says we need 488,000 more healthcare staff in the next decade. I apologise for flinging so many figures at your Lordships, but they underline a simple yet serious problem—and if we do not have credible, reliable, up-to-date numbers, how can we plan?
The health and care sector urgently needs better workforce planning. We need to know how much slack is in the system, and how it can cope not only with the expected but with the unexpected. We know from the experience of the last two years that the unexpected can, and so often does, happen.
Behind all those numbers are real people—professionals working flat out every day and every night to keep the show on the road, to care for patients and to keep them safe. I think we all agree that they are doing a valiant job, trying to be professional and compassionate, often in desperately difficult circumstances. But there is only so much that people can do when their team is not at full strength.
I am the first to admit that my amendment will not solve the workforce crisis. It will, however, provide the NHS and the care sector with a regular accurate national picture of the numbers of staff needed now and in future to meet demand. It will be publicly available, so we will all be able to see what is needed. It will provide a strong and much-needed foundation on which to take decisions about funding, skill mix, regional shortfalls and shortages of specialists. It will be published every two years. I think published annual assessments are too frequent. Two years is a reasonable interval: say, twice in the average time between general elections—one to say the last Government got it all wrong, and one to put it all to rights.
We could, of course, carry on as we are, without the information, a proper strategy or the ability to plan for the future—travelling in hope rather than expectation. That is not working. We already know that; the dozens of outside organisations which support this amendment— from royal colleges and professional bodies to charities and think tanks—know that; and, most importantly, the public know that, because they can see the pressure that NHS and care sector staff are under. To carry on like this would be to condemn our care services to flying blind through a storm. This amendment gives us the ability to set and navigate a sustainable course. With the extraordinary consensus behind this amendment and the impressive cross-party support we have had throughout Westminster, one would hope that it will find favour in your Lordships’ House and with the Government.
I listened carefully to the debate on a similar amendment in another place. The main argument Ministers made then was that the planned update to Health Education England’s 15-year strategic framework for workforce planning, known as framework 15, would do the job instead. I beg to differ, as do the 88 organisations which support this amendment. Previous versions of framework 15 have not quantified the workforce numbers, and the Government have been unable to confirm that the revised framework will set out the required numbers of staff. Even if the updated framework 15 had included projections of future needs—it did not—it would only be a one-off, and there would be no requirement regularly to update these predictions.
Might there be a concern about the financial implications of enacting this amendment? Do some worry that it may herald an increase in health and care staffing costs? I hope not, because to reject this amendment on those grounds would be a false economy. The NHS alone spends vast sums on agency staff, one of the most expensive and least satisfactory ways to manage an endemic workforce problem. The latest number I could find was for 2019-20, when the NHS in England spent an eye-watering £6.2 billion on agency staff, which was an increase on the previous two years. This amendment paves the way for reducing those expensive sticking-plaster solutions in favour of something sustainable and more cost effective.
There are, of course, many hurdles to overcome if we are to improve workforce planning and capacity management. There are issues that far greater brains than mine need to think about—the rise of AI, for example. In my household, married as I am to a farmer, as Members will know, AI has quite a different meaning. I am not referring to artificial insemination, but rather to artificial intelligence. What impact will that have on workforce planning and staffing? What about the rising trend of part-time work, telehealth or changes to skill mix? Those are all good questions that these clever brains stand a far better chance of answering if they have alongside them the regular, credible, national picture that this amendment seeks to provide.
In my view, we owe it to the staff working in health and care, and to the public who rely on them, to do better, to plan better, to prepare for the future and to ensure that the NHS and the care sector are at full strength. This amendment points us in that direction, and I hope the noble Lords here to answer the debate today will work with their colleagues in government to see the value—the worth—of this very simple amendment.
My Lords, in theory these amendments should not be needed, but in practice they clearly are, as the noble Baroness, Lady Cumberlege, has just so forensically set out. It is a statement of the blindingly obvious, particularly coming out of the pandemic, to say that we need better workforce planning at a time when staff are exhausted from having dealt with Covid for several years and the NHS is confronting the need to deal with the backlog of care.
But, frankly, it would be a statement of the blindingly obvious at any time, because the lead times for decisions on training for health professionals are such that they go beyond any individual term of Parliament or government manifesto. Universities need a strong signal as to what future demand will look like. The interconnectedness between health and social care means that we are actually thinking about a workforce of 3 million plus, and the materiality of getting it wrong over a five or 10-year period is bigger in this sector of the workforce than any other part of the economy. As we heard earlier—I think from the noble Baroness, Lady Walmsley—estimates from the Health Foundation, for example, suggest that on the current trajectory the gap could be more than a third of a million staff in the health service by 2030-31; and in respect of the social care workforce, Skills for Care talks about perhaps 490,000 additional posts being required over the period to 2035. Those figures may be right or they may be wrong, but there is not a forensic forum in which those debates are scrutinised and choices made. This is not just about more; this is about different.
It is not all doom and gloom. Over the last two years, during the most intense challenge the health service has faced since its creation, nearly 160,000 people have signed up to join the health and care staff and professions. We have seen applications for undergraduate nursing up by more than a quarter and a huge increase in applications for and interest in studying medicine, yet we have an acceptance rate of only about 52% for undergraduate nursing, according to figures from UCAS, and we are turning away bright and brilliant young people with fantastic A-level grades who would like to study medicine. That is a paradox which stems from the fact that, unlike the day-to-day running costs of the health service, those items which have the longest planning horizon—workforce and capital investment—are the areas with the shortest financial horizon.
Of course, it may well be argued by the Government that we are about to turn a corner and that although there has been a degree of short-termism hitherto, things are about to improve. But I am afraid that I think we are entitled to treat that proposition with a degree of scepticism, because although what has been said up until now may be blindingly obvious, in fact what we have been confronted with is wilful blindness. Health Education England, which should be looking at 10 years, does not yet have its running budget for 10 weeks’ time. If we look back over the history of recent years, we can see a series of missed opportunities. The Minister may assure us that we will be presented with this 15-year further vision from Health Education England this coming summer, which will, of course, be welcome. But if we remind ourselves of the history since 2014 or 2015, as I say, we can perhaps be a tad sceptical. Obviously, I draw attention to my prior NHS interest, and everything I am about to say only draws on the public record, just to clarify that point.
It was back in 2014 that the NHS Five Year Forward View talked about the service changes that were required, but it was not permitted to talk about future capital investment, social care or workforce training, since they were being kept separate. So, in summer 2016, the Department of Health and Social Care was going to produce this detailed quantified workforce plan instead. Twenty-sixteen came and went and instead, in December 2017—three years after the Five Year Forward View—Health Education England launched a consultation document which said: “Your responses will be used to inform the full strategy to be published in July 2018 to coincide with the NHS’s 70th birthday.”
Twenty-eighteen came and went, and answers saw we none. Then in June 2019, we got another, in this case interim people plan, with lots of excellent content but unfortunately no actual numbers and no new pound notes. Despite the fact that it promised:
“We will aim to publish a full, costed five-year Plan later this year”
“the full range of additional staff needed”.
But again, “later this year” came and went, and no such documents saw the light of day, until in July 2020 we had a one-year people plan which, at that point, was covering just the next eight months. Fear not, though, because it said:
“Further action for 2021/22 and beyond is expected to be set out later in the year”—
“once funding arrangements have been confirmed by the Government.”
That did not happen.
Instead, in July 2021, last summer, the Department of Health and Social Care again commissioned Health Education England to start from scratch. Last November, HEE published a short PowerPoint—commissioned from a firm of accountants—with the discouraging disclaimer on the first page that:
“We do not warrant or represent that the report is appropriate for your purposes”
and “no warranty is made as to the accuracy of any data”. As it happens, that does not really matter because there were no real data in the document anyway, which came to startling conclusions such as “workforce demand will be affected by demography and disease”.
I think we are entitled to say that this litany tells us that what, to everybody else, is blindingly obvious has instead been confronted with wilful blindness. What explains this? Is it a lack of interest on the part of the committed people to getting this right? No, it is not—some excellent work has been done. Your Lordships may take a clue from a statement that Jeremy Hunt, the former Secretary of State and now Chair of the Commons Health and Social Care Committee, made last Tuesday, when he said that “the Health and Social Care Committee has recommended on numerous occasions that we should have independently verified forecasts of the number of doctors, nurses and other staff that we should be training for the future. But that has been blocked consistently by the Treasury”.
Without in any way commenting on or editorialising that, the Minister may want to take the opportunity to confirm whether that is indeed the case. But just on the off chance that he does not refute the statement Jeremy Hunt has made, then that, I think, tells us that unfortunately, these amendments are necessary and will strengthen the hand of Health and Social Care Ministers in the future. I cannot help thinking that, in their heart of hearts, past Health Ministers know that they would have benefited enormously, were these amendments on the statute book. I am afraid that, if the Government choose not to support these amendments—as I hope will not be the case—that will be proof positive that they are very necessary. Therefore, I hope they will recognise that ignorance is not bliss and if we do find ourselves in that situation, this House will take the opportunity at Report to give the Commons another go.
My Lords, listening to my noble friend Lord Stevens of Birmingham, I am beginning to feel the pain of his frustration at being chief executive of the NHS and not being listened to in order to fix such an important issue as workforce planning. Also, there is a bit of déjà vu that he may remember, along with some of my colleagues who were took part in the Lords committee inquiry into the long-term sustainability of the NHS and adult social care.
Let me argue the same issues that he just presented. The report on the long-term sustainability of the NHS and adult social care, published in April 2017, looked at data on demographic and disease burden projections of the population over the next 15 to 20 years. It identified a lack of long-term workforce planning as a key threat to the long-term sustainability of the NHS. The Committee heard from the then Secretary of State, the right honourable Jeremy Hunt, who had this to say:
“workforce planning is an area where we have failed… Brexit will be a catalyst to get this right… That is an area where we need to be much more strategic”.
That was nearly five years ago and yet, there is no strategic healthcare workforce plan from the Department of Health and Social Care, as we just heard.
The solution is not going to come from an outside body, no matter how influential. It has to come from the centre, from the leadership of the NHS and social care, and not one in the isolation from the other. What we have heard from the centre and NHS organisations is many publications identifying the problem, but not the solution with a long-term plan. We are told that this may be coming in April 2022—or perhaps later.
On the other hand, there are several detailed authoritative documents on the NHS workforce from think tanks, NHS providers, the BMA, the nursing councils and many others, who have been grappling with this issue and trying to find a solution for a long time and advising the Government on how to do this. There is no lack of authoritative reports based on data related to long-term projections of population, its demography, health needs and the workforce needed to deliver them. For example, an extensive, well-researched report by Dr Latifa Patel, a respiratory paediatrician, and Dr Wrigley, a GP of medical staff in England, projected to 2045—based on population and disease data—the number of doctors needed in each speciality and possible models of plans to deliver on this by 2032. A document extending to 60 pages is not only highly informative and well-researched but identifies a way forward.
Since the Health and Social Care Act 2012, there has been inadequate workforce planning, fuelled by inadequate regional and national workforce data and a lack of accountability for it at government level. We are not training enough doctors, despite record numbers of people applying. The latest figures, as the noble Lord, Lord Stevens of Birmingham, mentioned, show a 21% increase on previous years in applications to medical schools of highly talented young people. This means the NHS is ill-equipped to tackle the backlog of care, is not prepared for future public health crises and cannot meet patient needs, either now or in the future.
If we compare England with EU nations within the OECD, which have an average of 3.7 doctors per 1,000 people, the medical workforce in England is currently short of around 49,000 full-time equivalent doctors. Without significant intervention regarding the current rate of growth, the estimate is that the future medical workforce shortage will be between 26,889 and 83,779 full-time doctors by 2043. Such precise numbers show how well-researched this document is. Each full-time doctor in NHS England is doing an average of 1.3 full-time equivalent roles. I have three of them in the NHS and I can see what they do—although I tell them they are lazy compared to me.
The NHS faces a huge backlog of care, post pandemic. Estimates are that there were 3.37 million fewer elective procedures and 21.4 million fewer out-patient attendances between April 2020 and March 2021. On top of this, the population is expected to grow around 9% over the next 25 years to more than 61.5 million. At least one in four adults will be aged 65 or over, and the number of people aged 85 or older will have nearly doubled to 3 million by 2043.
Staff retention is poor and is set to worsen without intervention. This is caused largely by the vicious cycle of medical workforce shortages, overworking existing staff, years of demoralising pay erosions and punitive pension taxation rules. We have 1,307 fewer qualified full-time-equivalent GPs now than in September 2015, while shortages of specialist occupational physicians and public health doctors are severely impacting efforts to keep the population healthy. The shortage of medical academics means that training the next generation of doctors has become even harder. You do not just get medical or nursing graduates by increasing the intake: you have to provide the resources—manpower, equipment and capital funding—to train them. In the last 10 years, the senior clinical academic workforce reduced by 27%, while the number of medical students grew by more than 25%. For those of us who have trained medical students and postgraduates for years, medical undergraduate training committed at least two sessions a week from each one of us—that is one day—apart from undertaking extra duties. Not a single region in the country meets the current OECD EU country average of 3.7 doctors per 1,000 people.
The medical workforce itself is ageing, meaning that we risk losing around 16,818 secondary and 8,676 primary care doctors—a total of up to 25,494—in the next 10 years due to natural retirement. One in five doctors is saying that they will leave their career in the NHS altogether post pandemic. I repeat: one in five. This figure might be as high as 31,820 doctors. Those noble Lords who have not seen the recent report by the GMC might like to look at it, because it confirms these findings. Other health services carry a significant number of vacancies, but, even if all currently known vacant medical posts were filled tomorrow, we would still need 42,528 more full-time-equivalent doctors and doctors in training to meet the OECD EU country average of 3.7 doctors per 1,000 people in England.
International medical graduates have always been, and will remain, a key part of our medical workforce. However, international recruitment must not come at the expense of developing countries, so a sustainable, long-term workforce strategy is needed. While there is increasing multidisciplinary working within healthcare services, while there will be technological advances, and while non-medical roles have expanded in recent years, the doctors’ unique skill set is essential.
The report by Patel and Wrigley also makes estimates of cost based on data, along with reports from the Health Foundation and the Institute of Fiscal Studies report of 2018. To meet the current shortfall in the medical workforce by 2030 and increase training slots would require in the region of about £8 billion over the next three years. That is not so much when you consider, as the noble Baroness, Lady Cumberlege, indicated, that we are spending £6 billion on locum or agency fees.
I have spoken about the medical workforce, but I absolutely accept that similar problems—and perhaps even worse—need addressing in nursing and other healthcare professional workforces. I have no doubt that my noble friend Lady Watkins of Tavistock might well address that issue. I make a case for an urgent need—not in two years or three years or four years—for a strategy on health and social care workforce planning from the Department of Health and Social Care. The amendments in the name of the noble Baroness, Lady Merron, do this, and I have added my name to her two amendments. They put a duty on Health Education England to do this, and a further duty on the Secretary of State to report annually to Parliament, not only on the workforce plans but on the funding to support the plans.
There is only one thing that I would add, if the noble Baroness would accept it, and that is for the House of Commons Health and Social Care Committee to have an independent expert analysis carried out every two years on the delivery of government policy commitments on the health service workforce. An example of such an exercise is the one that the committee carried out establishing an expert panel that reported on mental health services and identified the gaps in the delivery of policy commitments in mental health. I strongly support the noble Baroness’s amendments.
My Lords, I declare my interest in the register. I am making a very short intervention just to talk about care workers. While there has been a great emphasis on the NHS, the crisis that the care sector is facing now is absolutely devastating. I was with care managers this morning, and they were wondering how they were going to manage the next few weeks, never mind the next few years. I urge the Government to understand that it is not just about added training and it is certainly not about planning for the future when the crisis is now. The crisis in the future cannot actually be estimated now, because we are in a crisis now.
So I urge the Government to look at the key issue around the sectors, and that is money. It is funding. We devalue the very people we expect to have value for in looking after the elderly, the disabled and those who need help. I came here not wanting to intervene today, but I was actually pushed by what I saw this morning with my care managers. They are absolutely struggling, trying to work out where they are going to find these magical beings who do not exist, because they have left the sector as a result of being so poorly paid, so badly treated and so deeply undervalued by everyone. I just wanted to put that intervention on record because, while we do need workforce planning, the problem is that we are so far behind the curve that it is going to take one mighty big plan to get this right.
My Lords, I would like to follow the noble Baroness because my amendment relates to this issue. My Amendment 174 would require the Secretary of State to publish a report on the work undertaken to bring parity of pay between health and social care services.
When reflecting on the pandemic, it is clear that we owe an enormous debt of gratitude to our key workers, who went above and beyond the call of duty to keep people safe and healthy. Their efforts resulted in a deserved pay rise for NHS front-line staff. However, it highlighted the disparity between the treatment of healthcare staff and social care staff. While we clapped for both every Thursday, the gap in pay and reward between the two professions has grown even larger. This amendment reflects the undeniable need to see care staff recognised equally alongside NHS staff.
The social care workforce is, and needs to be, highly skilled. It holds a heavy weight of responsibility for the well-being and safety of vulnerable adults and children. Staff are trained to support medication, undertake PEG feeding, deal with seizures and administer first aid. They help people manage their finances, health and well-being, and they provide emotional support. They operate within a highly regulated sector, necessitating an understanding of health and safety, mental capacity and deprivation of liberty law, safeguarding and even how to positively manage challenging behaviour. The importance of their role cannot be underestimated. Indeed, the same can be said for other, highly skilled allied health professionals, such as nurses and occupational therapists, whose breadth of interventions provide enormous value within the care sector, as well as within the NHS. The turnover rate is just so high. It is unsurprising that staff such as nurses and OTs who can do so are more likely to seek better paid employment in the NHS.
A report recently commissioned by Community Integrated Care shows that many front-line workers in social care are financially “significantly undervalued” by as much as 39%—nearly £7,000 a year—compared to equivalent publicly funded positions. Social care struggles to match pay conditions available within the health sector, including pensions, annual leave entitlements and sick pay. That means that, when faced with the choice of working in either sector, individuals are more likely choose to work in health, if they can. We must help foster a culture of collaboration between the NHS and social care.
Skills for Care estimates that the adult social care workforce in England employs over 1.5 million people, yet there remains a major recruitment and retention crisis which, without intervention, is only likely to get worse. Currently, there are over 100,000 vacancies—that is around 6.8%—with projections estimating that nearly 500,000 new jobs will be needed to meet demand within social care by 2035. The turnover rate of staff is estimated to be over 30%, and higher still among those on zero-hour contracts.
Pay is not a panacea for addressing this issue. Much of it comes down to better wages being offered in other sectors which are able to use market forces to drive up employee pay. Furthermore, if terms and conditions are more closely aligned between social care and the NHS, staff may be able to move more easily between sectors, providing the continuity of care for their patients in the community, which is so valued by so many people.
Social care has been defined as a low-paying industry by the Low Pay Commission every year since the first report of the Low Pay Commission on the national minimum wage in 1998. The average pay for support workers in England who assist people to live independently in the community is £17,695, or £9.05 per hour, which is 45p per hour below the real living wage—that is the average. It seems nonsensical for a single system to have staff working at similar levels but some being paid significantly less than others. The Government have previously argued that, because of the existence of private providers in the care market, they cannot mandate a level of pay for care staff. But this just does not hold up to scrutiny: providers are paid an hourly rate for the contracts they are given by the local authority. This means that there is a conduit through which a fair rate for providers, and by extension employees, could be set.
The continued insistence that an increase in the national living wage is suitable remuneration for care staff does not reflect the level of skill and dedication that they display. While this may reduce the barrier to entering the adult social care workforce, we are still left with problems retaining what will go on to become a much more experienced workforce. There is very little incentive to stay in terms of pay promotion, and the experience pay gap has reduced even more, to something like 1% per hour in the past year. We must address this issue to support this workforce, now and for the future.
Higher pay and lower vacancy rates have been associated with more favourable outcomes during inspections by the Care Quality Commission, which is not surprising. Put simply, a stronger and more valued workforce improves patient care and retention. The demand for the skills of the workforce, now and for the future, means that ensuring parity of pay and conditions between the health and social care sectors is of paramount importance in the care, rehabilitation and protection of people who need this support.
I thank Mencap for a very good brief, Skills for Care for excellent statistics, and my noble friend Lady Finlay for supporting my amendment. I hope that the Minister will see its value.
My Lords, it is a pleasure to follow the noble Baroness, Lady Hollins, and I completely support what she and the noble Baroness, Lady Verma, have just said. Unless care wages equate with the minimum for personal care in the NHS, we will never resolve this problem. I have been told by the National Care Forum that that means approximately £13.50 an hour. I would like to see that on the record.
The main reason I rise is in support of Amendments 173 and 171, which reflect other amendments looking at the need to ensure that we get workforce planning right for the future. Although we are talking about the future, we are also talking about the immediate crisis in social care.
I was amused at 6.36 pm to get a message from NHS Professionals, which said: “Dear Mary, you are receiving this email because you are registered on our NHS pathway for professionals. We still have many new opportunities that you would be interested in, so please feel free to log in and see now.” I do not know whether the noble Baroness, Lady Chisholm, who is just walking in now, has had the same email from NHS Professionals, but we both logged on at the same time—and she is nodding she has. We will stay here for the time being.
The pandemic has placed a spotlight on the health and care workforce and the pressures it sustained. However, these pressures are against a background of persistent under-recruitment, under-retention and under-representation. This shortfall has serious implications for patient and staff safety, as well as the efficiency of health and care services. In part, as others have said, this has been ameliorated by overseas recruitment. However, as a co-editor of the World Health Organization’s State of the World’s Nursing report last year, I have to say that that is not sustainable or ethical. However, I particularly congratulate the Chief Nursing Officer, Ruth May, for her initiative that enables and encourages refugees to register as nurses in this country, which is clearly an ethical practice.
A strategy to comprehensively monitor and meaningfully respond to the shortfall is essential to support the recovery and development of a strong, safe and sustainable workforce. As it stands, I do not believe that the Bill adequately mandates the actions required to achieve this ambition. As others have said, across the NHS there is a shortage of almost 100,000 full-time equivalent staff, with nursing staff accounting for 40% of vacancies in England. In the last five years, we have seen less than a 10% increase in mental health nursing staff and a continual decline in learning disability services. I understand there is an NHS England ambition for 21,000 new posts across the mental health system. This appetite for expansion—with the view that it translates to a sufficiently staffed and skilled workforce—is welcomed perhaps more so than ever, as 2.8 million people, or 5% of the population, had contact with secondary mental health, learning disability and autism services during 2020 and 2021.
As we are all aware, the workforce shortage is not limited to the NHS. The turnover rate of registered nurses in adult social care is four times higher than in the NHS, with marked regional differences. Getting the right number of staff with the right skills therefore remains a challenge and requires urgent review to maintain quality patient care. In care homes, the shortage of registered nurses has caused some providers to renounce their registration to provide nursing care, forcing some residents to find new homes. In hospitals, high staff turnover and the use of agency staff have contributed to excessive restrictions and blanket approaches to care for people with learning disabilities and autism, for example.
We have also seen an impact on growing waiting lists. In the first quarter of this year, only 61% of children and young people with eating disorders were seen within one week for urgent review—a 72% reduction from last year and falling below the national standard. I therefore welcome the focus on children and young people’s mental health teams, including the proposed approach to facilitate a much better system in schools. However, such healthcare workers will need to be included in workforce reviews to facilitate a system-wide understanding of current and projected needs and resources. We should celebrate that so many people want to become nurses and encourage them to do so by investing not only in university places but in apprenticeship schemes that enable a wide variety of people from different cultural backgrounds to enter the profession.
While workforce data is collected monthly and subject to validation, it is segregated by sector, which makes some comparisons difficult. There are also known data limitations. In social care, only half of the workforce is recorded; in general practice, sessional practice nursing is not directly comparable with the main workforce; and in the independent health sector there is no complete estimate of the total workforce, despite the fact that it provides significant NHS services.
All this necessitates an imperative call for a workforce strategy that goes beyond a five-year snapshot of the NHS. Rather, a collective effort across the health and care labour market, including community nursing and midwifery, is warranted to annually capture and forecast workforce shortages and requirements over time, with a five-year government strategic response and annual update. Without these amendments, England risks a future health and care workforce that lacks the sufficient capacity, competence and diversity that is necessary to achieve more integrated care and safely promote health and support the changing needs of the population.
My Lords, I will speak briefly on Amendments 170, 171 and 173. As a former Chief Nursing Officer, I recognise the challenge of ensuring the right number with the right skills of those providing healthcare to meet the needs and the future needs of the population. As someone who, while the Government’s Chief Nursing Officer, was given the objective of finding 60,000 nurses, I understand that it requires a whole-systems approach. I often felt it was about science and art—the science was in the work that went on nationally but the art was in the way it was applied locally on the ground. The noble Baroness, Lady Walmsley, talked about how work on the ground is often not about intuition because that is about experience and knowledge; it is about how it is applied on the ground. I also reflect on the fact that although it was my role with all those working around me to find 60,000 nurses some years ago, we are seeking to find almost the same number today. That demonstrates the fact that we do not have a sustainable model of workforce planning and that we need to do better.
We have already heard how the Bill requires the Government to publish a report that describes the systems in place for assessing and meeting the needs of the workforce. We have already heard that that does not go far enough. In meeting workforce needs, systems are required for both planning and supply, but that does not ensure that it will happen. I believe that we need a system that has accountability, that puts into place long-term planning, and that is funded.
The Secretary of State needs to be held accountable for both workforce planning and supply, because there are some things that only the Secretary of State can do. For example, if the workforce planning systems are not co-ordinated at a national level, there is often limited ability to respond to local variations on the ground, such as those between rural and urban settings or between professions or sectors. For example, responding to local variations may require national changes, such as in training or registration.
There are also parts of the workforce planning system for which only the Secretary of State can be accountable. For example, you can assess and put in place workforce plans but unless they are funded, it is done in vain. There are also actions that are often taken at a national level by government, which can impact on workforce supply and which only the Secretary of State can resist. We have seen national policy influence recruitment and retention: for example, as we moved away from the nursing bursary, as we have seen changes in immigration policy and in the challenges faced by the medical profession around its pensions. All those impact on recruitment and retention.
The Health and Care Bill must have embedded in it accountability for workforce planning and supply sitting with the Secretary of State. This will not only ensure good supply but will prevent staff shortages, improve patient safety and the quality of care. If this is not resolved, we will see those deteriorate.
Finally, on sustainability, we have heard how planning for the workforce takes time. We have heard how long it takes to take train a doctor or a consultant or even a clinical nurse specialty. These periods of training reach over the span of a Government. We need a system that does not just respond to the needs of a Government but beyond them, to ensure that our horizons are not limited by politics but by the needs of a population. Our workforce provides not just quality care to an individual but to a community. We have heard how, if we fail to provide the right workforce, we will fail the other aspirations in the Bill.
My Lords, I have added my name to Amendment 146 in the name of the noble Baroness, Lady Merron, but I support all the amendments in this group. Taken together and perhaps integrated a bit better, they strengthen the focus in the Bill on workforce issues and workforce planning. I also congratulate the noble Lord, Lord Stevens, on his contribution to open government.
For too long, we have been preoccupied with the funding of our health and care system and have tended to assume—I confess that as a Minister I certainly did this to some extent—that if Governments made enough money available, we would be able to acquire the staff we needed, always forgetting, I think, that health and care is a highly labour-intensive industry, possibly the most highly labour-intensive industry in our country.
We were often very good at masking the shortcomings in our planning system by historically relying on recruitment from abroad. There were doctors from Africa, India and Europe, nurses from the Philippines and elsewhere, and we had a lot of staff coming in from the EU to work in our social care sector. Brexit and our national preoccupation with limiting immigration has changed all that, and that is before we calculate the effect of Covid on health and care staff recruitment. To give your Lordships just one example, pre-Brexit, 40% of the social care staff in London came from the EU. You simply cannot make that ground up very quickly.
Today’s reality for recruiting health and care staff is that we are operating in a highly competitive national and international labour market. That situation will not change any time soon. The probabilities are that we will have to pay more for staff and give more thought to our working practices and conditions. We will have to do a much better job of planning ahead and take much more seriously the training, support and recruitment and retention of this increasingly scarce resource—people.
I suggest that Ministers—I include all of us who have been Ministers—must stop political bragging about how many new doctors and nurses a Government will produce, often without the foggiest idea of how long it will take to do so. Ministers might want to give more consideration as to whether they have the right skills in the sector in the first place, before commissioning the training of highly paid, highly skilled professionals. We have not done a very good job of looking at the extent to which many of the jobs done by doctors could be done by other professionals. Our attempt to train nurses in prescribing has been only half-hearted in using the skills that we have paid for them to develop.
The number of amendments in the Bill that focus on workforce supply and its use is considerable. It is clear from listening to this debate and looking at all these amendments that, across the Committee, there is a strong desire for the Bill to include many more provisions about measuring and assessing the adequacy of the health and care workforce and planning ahead to meet future needs. The amendments in this group make clear that this work needs to be done at both local and national level, and changes in the Bill will need to reflect that consideration. I suggest that we need to get together, across the Committee, to collect and secure the right mix of amendments on Report. The Government would do well to begin discussions with all parts of the Committee on amendments that would meet the concerns expressed today.
While I support the amendments in this group as making a big improvement on the current situation, I do not think they go far enough to deal with DHSC short-termism. The noble Lord, Lord Patel, mentioned the House of Lords Select Committee that reported in 2017. Much more should be done because, as my noble friend Lord Stevens eloquently described, we may not be able to trust any Government to keep their mind consistently on this issue. History is not terribly reassuring on that. I am not making a party-political point; across the parties, there is a danger that we lose sight of this issue when it becomes inconvenient. Even a well-intentioned Health Secretary can be subdued by his colleagues in the Cabinet—I mention no particular names or offices.
That is why I have tabled Amendment 285, which talks about establishing an office of health and care sustainability which would bring together the issues of money and workforce planning. It basically implements a recommendation from the 2017 Select Committee report and is based on the experience of the Office for Budget Responsibility. The noble Lords, Lord Patel and Lord Kakkar, have tabled a similar but slightly less detailed amendment with Amendment 286. Between now and when we reach those amendments, we need to consider whether we are confident that amending the Bill to rely on the Secretary of State doing the right thing, without some independent outside influence, is the right way forward. We want to give the Secretary of State the job, but we also want to ensure that he does it. I mention, if I dare, that the amendment proposed by that 2017 report was put to Jeremy Hunt, who did not act on it—though I am pleased to see that the sinner has repented and decided that there was perhaps some merit in having a national body to look at this kind of issue.
My Lords, I add my voice in support of Amendment 170, so ably and brilliantly introduced by the noble Baroness, Lady Brinton, my noble friend Lady Cumberlege and the noble Lord, Lord Stevens.
At Second Reading, I spoke of my personal experience along the timeline set out by the noble Lord, Lord Stevens, as the person charged with developing the 2019 people plan with said absence of numbers. I do not wish to go into more detail on the history; I would rather spend the brief time I have available talking a bit more about why I think this amendment is needed and attempting to pre-empt some of the potential objections which I suspect will come from my noble friend the Minister.
A number of people have alluded to it, but we should be under no illusions that this is the most important debate we will have on health and social care. All our fantastic, lofty ambitions for our health and care system are for naught if we do not have the people to deliver them—and we should be under no illusions that we do not have them today.
I add my voice to those of the noble Baroness, Lady Hollins, and my noble friend Lady Verma: there is undoubtedly an important point about ensuring that healthcare assistants, nurses and managers in social care are paid appropriately. We also need to face the fact that we do not have enough people working in health and care in every single role in the system.
This is not a UK-only problem. As the noble Baroness, Lady Brinton, and the noble Lord, Lord Patel, said, this is a global issue. We cannot rely on people from outside the UK alone to solve our problem; we have to solve some of this ourselves. We undoubtedly need more people, but I would argue that we also need to work differently; we need both more and different. We need to address the way we work in health and social care, which is at the heart of this Bill. We need to embrace new professions and do the forward planning to make that possible, whether that is recognising sonographers as a registered profession; pushing forward on physician associates, where we are some 10 years behind other countries in the world; or developing an approach to credentialling which enables our clinicians to have more flexible careers, as science and technology change through the course of their lives. All of these ways to work differently from the way we operate today are as important as having more people. Neither more nor different is possible unless we start by being honest about the size of the problem, which is why Amendment 170 is so important.
I believe there are two substantial disincentives for this amendment being accepted. A number of your Lordships have alluded to the first one: anyone running a large people-based organisation is always tempted to focus on the urgent today and not invest in training and development for the future. It is just too tempting for the NHS, as well as the Secretary of State and undoubtedly the Treasury, to want to retain the flexibility to focus on the short term and raid the training budget for the future. Any one of us who has run any organisation knows that that is a human temptation. This does not make them bad people and it is not party political; it is just the reality of running a large organisation. That is why legislating to force transparency is so important.
The second major disincentive relates to a view that I suspect has been held in the Treasury for the best part of 20 years and which is counter to most economics. It is a belief that the way to control workforce costs in the NHS is to constrain the supply. I am not a brilliant economist, but most economics is the other way round: the way to reduce the cost is to increase supply. I have no doubt that it is quite a strongly held view in Her Majesty’s Treasury that the way we control workforce costs in the NHS is by constraining the supply. The reality is that that market mechanism is completely failing.
You have to look only at the costs the NHS is paying for locum, agency and bank staff. A recent Getting It Right First Time report, published last autumn, stated that 27% of workforce costs in emergency departments are for locum, bank or agency staff, which tells you that they are not properly staffed. If you are a young junior doctor in your third year in your career and you work as a locum for one week, you will earn £5,800, but if you work for the NHS for one week, you will earn £3,300. We should not be surprised that junior doctors with large student debts want to work as locums, yet we also know that that materially reduces their fulfilment and the quality of the care they deliver. The economic incentives are not working, despite the deeply held view that if we constrain the supply the NHS will somehow magically transform itself.
That is why we need to put this in the Bill. We do need more people, but we also need to drive incentives for transformation, and we will do that only if we face into the challenge. Those working in higher education can plan only if we give them a signal, and transformation teams can challenge the way we work only if we are honest about the need for that transformation.
One final reason I really urge my noble friend the Minister to accept this amendment is that our wonderful people, who have worked so hard in health and care over the last two years, need hope—and we can send them the strongest signal of hope that we really hear them, that we really understand the people challenges that they face, by putting this in the Bill.
My Lords, I support Amendment 173 in the name of the noble Baroness, Lady Merron, to which I have added my name, and I broadly support the amendments in this group.
Many noble Lords have identified the question of workforce as the most important single issue that the Bill has to address. Without effective workforce planning, the NHS, as we have heard—and, indeed, the care system—is in peril. Previously, our country and the National Health Service have depended on overseas doctors and nurses to come and fill large numbers. That has been the principal basis of workforce planning for many years—indeed, decades. But that is no longer a viable option. The World Health Organization has estimated that, globally, there will be a shortage of some 18 million healthcare professionals by 2030. That will be a particularly difficult challenge across the globe, and it means that we can no longer depend on importing healthcare professionals to meet our ever-increasing needs. This is well recognised by all who are responsible for the delivery of healthcare and, indeed, by Her Majesty’s Government.
The question is: how can we dependably plan for the future? Unfortunately, it has to be accepted—indeed, it has been accepted in this debate—that planning to date has failed miserably. That is not a malicious failure, but it is a reality, and one that we can no longer tolerate. That is why amendments in this group that deal with the requirement for independent planning and reporting on a regular basis to provide the basis for determination and projecting future health and care workforce needs, are appropriate—indeed, essential.
My noble friend Lord Warner raised a separate issue about a group of amendments that will come later in the Committee’s consideration, which propose the establishment of an independent office for health and care sustainability. This is a recommendation of your Lordships’ ad hoc Committee on the Long-term Sustainability of the NHS and adult social care, chaired by my noble friend Lord Patel. It is this emphasis on ensuring that there is independent, long-term planning and projection that can provide the fundamental and accurate foundations for workforce planning. We need a broader assessment of what the demand for healthcare will be, and that demand is complex and driven by not only demographic change but changes in the way that we practise, changes in expectations, adoption of technology and changes in working practices. That all needs to be brought together to provide the foundations for planning. Without this emphasis and this obligation secured in the Bill, the NHS and adult social care in our country will not be sustainable.
I very much urge the Minister, in considering this group of amendments, to help your Lordships understand why it would be wrong to secure this emphasis in the Bill. If Her Majesty’s Government are unable to secure this emphasis in the Bill, how can they reassure noble Lords that the failures in planning that have dogged NHS performance with regard to workforce over so many years will not be repeated in the future?
My Lords, to state the obvious, without a workforce plan we cannot have a workforce. Amendment 170 certainly seems to get to the heart of the issue, which was so well introduced by the noble Baroness, Lady Cumberlege, and my noble friend Lord Stevens.
Others have spoken about the medical and nursing workforce, and therefore I will not repeat those comments. I want to put a plea in for the allied health professionals, because many of them work outside the NHS, so, while we talk about NHS planning, we will undersupply chronically if we do not recognise where else they work. Some 25% of physiotherapists work with other providers such as the military, prisons, hospices and occupational health services. Some 50% of podiatrists work outside the NHS, and speech and language therapists often work with people in education as well as in the criminal justice system, social enterprises, and in the voluntary and third sectors. That is why I tabled Amendment 172.
In Amendment 214, I have tried to address the problem that Clause 79 abolishes local education and training boards. As the noble Baroness, Lady Harding, said, without access to education, time for CPD, funding of courses and backfilling, we will not get the rapid movement of our staff into different areas as the provision changes. Such local assessment could then feed into national planning processes, as outlined in Amendment 170.
I will give a few bits of data to support Amendment 174 on social care, to which I added my name. Skills for Care found that 24% of the adult social care workforce are employed on zero-hours contracts. That means that they cannot get mortgages, et cetera. Care workers represented the highest proportion of workers on zero-hours contracts, at 35%. Those on slightly higher grades are more likely to have full contracts. In the community, a Community Integrated Care study found a gap of £7,000 between equivalent roles in social care and the NHS. With that large gap, it is hardly surprising that social care does not retain its staff. There is no joined-up recruitment yet, and there is no local or national training planning that covers health and social care.
This group of amendments is absolutely essential, and it would be a dereliction of our duty to ignore the messages from this debate.
House resumed. Committee to begin again not before 8.30 pm.