Health and Social Care Bill

Memorandum submitted by million+ (HS 112)

About million+

1. million+ is a university think-tank which provides evidence and analysis in respect of the impact of policy and funding regimes on universities, students, graduates and the services that universities and other higher education institutions provide for business, the NHS and the not-for-profit sectors.

The NHS and Social Care Bill and the abolition of the Strategic Health Authorities :

NHS workforce planning, education and professional development

2. The abolition of the Strategic Health Authorities (SHAs) has significant implications for NHS workforce planning and for the future education, training and professional development of NHS non-medical staff – issues which have been the subject of very little parliamentary and public scrutiny to date. Currently, nursing, midwifery and allied health profession education in England is provided via a national standard contract between the SHAs and individual universities which run faculties or Departments that specialise in particular NHS professional education and training and have been approved by the relevant professional body. The SHAs are therefore currently the planning and awarding bodies for these education and training contracts in England [1] .

3. Funding for nursing, midwifery and allied health professional education (NMET) is one component of the ‘Multi-Professional Education and Training (MPET) budget which is included in DoH funding of the SHAs . Other components provide funding for postgraduate medical and dental education (MADEL) and support for the practice teaching of medical students (SIFT). The current budget is around £4.5 billion. MPET funding is allocated for NHS workforce education and development for all areas other than for medical training and courses. The Higher Education Funding Council for England ( H efce) allocates student numbers to universities for medical training and courses as well as for dentistry, pharmacy and healthcare science.

4. At present MP ET funding for nursing , midwifery and allied health profession education provides for

· pre-registration education

· post-registration education

· continuing professional development.

Universities have significant revenue (staff) and capital investments in NMET/ MPET contracts and employ academic staff who are experienced practitioners in their field.

5. In addition to nursing and midwifery, MPET funding covers allied health professions such as radiographers, physiotherapists, podiatrists where similar arrangements in respect of registration apply. For example, radiographers must be registered to work in the NHS. For this, they need a degree in radiography from an education centre approved by the Health Professions Council (HPC). All qualifying radiography courses are at degree level and most are three-year courses and students are normally based in a university and in hospital departments for an equal amount of time. Students choose at the outset whether to study for diagnostic or therapeutic radiography degree courses.

Example: Nursing

To work in the NHS, nurses must hold a degree or diploma in nursing (a "pre-registration" programme), which leads to registration with the Nursing and Midwifery Council (NMC), enabling them to practice as a nurse. Degrees and diploma programmes comprise of 50% theory and 50% practice, with time split between the higher education institute (HEI), which runs the course, and practical placements in a variety of healthcare settings.

New entrants to the nursing profession from September 2013 in
England will have to study for a degree . However, diploma courses will be phased out between September 2011 and early

2013. As a result, some universities in England will only offer the new degree programme from

September 2011, while others will continue to offer the diploma and current degree programmes throughout 2011 and 2012. By September 2013, all nursing programmes will be degree-only.

Part-time pre-registration nursing programmes are provided by some universities and normally last for five or six years. They are available to staff working in the NHS , usually as an assistant or an associate practitioner with qualifications up to NVQ level 3 (or equivalent). Staff are employed by the NHS which provides support in terms of time-off to attend on a part-time basis.

R efocusing MPET commissioning and budget reductions

6. The D oH in England has signalled that the MPET budget will be cut by up to 15% over three years commencing in 2011/12 . Universities in England have confirmed th at the number of commissions is likely to decrease by around 10-15% and that they have been advised by SHAs that these cuts w ill be front ended i.e. with greatest reductions in year one (2011/12) .

7. Within this ove rall reduction, indicative education commissions received by u niversities from SHAs for 2011/12 demonstrate considerable variation with in each SHA region and w ithin individual profession s , with some areas (such as physiotherapy) likely to receive even larger cuts over the period. At present, there appears to be a wide level of variation in the number of students being commissione d. For example , in midwifery some universities are facing a 50% cut while others are being asked to substantially increase the number of new midwives that they are training. More recently, the Government has announced an intention to increase the number of Health Visitors.

8. The extent to which the DoH and BIS (the Department responsible for u niversities) have undertaken any assessment of the risks of re ducing the MPET budget and abolishing the SHAs as commissioning bodies from April 2012 , is unclear. Some u niversities receive approximately 25% of their total income from NHS - funded health professional courses. U ncertainty about the arrangements for the commissioning and award of these contracts from 2012/13 is creating a financial risk which will coincide with the introduction of the new fees and funding regime for other undergraduate courses in England . If there is continued delay a nd uncertaint y in future NHS planning and commissioning arrangements , universities may have no option but to consider making well-qualified and experienced staff redundant if there is no clarity and further anticipated reductions in student numbers .

9. This poses an obvious risk to future NHS education and training provision. If reductions in the MPET budget are front loaded and a new commissioning system which places greater emphasis on local decision making , is i ntroduced in the short timescale envisaged in the NHS and Social Care Bill, there is every prospect of ‘a boom and bust’ approach to healthcare education commissioning. There are therefore considerable concern s a s a result of the proposal to abolish the Strategic Health Authorities and the failure of DoH and the Bill itself to assign clear responsibility for the future planning and commissioning of MPET and NMET education and training.

Health Education England: A Special Health Authority?

10. DoH has attempted to address some of these problems by issuing a consultation Paper, Developing the NHS workforce, on the future of education and training in England. However, the robustness and effectiveness of the arrangements currently proposed are open to question. In addition, there is a very significant concern that DoH has used the consultation paper and the NHS reforms to propose that the MPET budget for nursing, midwifery and the allied health professions should no longer fund post-registration and continuous professional development (CPD) provision and be restricted in the future to pre-registration programmes (to be paid for through a levy, the operational details of which are unclear).

11. The DoH’s proposal to exclude post- registration and CPD from the MPET/ NMET budget from 2012/13 poses a further risk to the future viability and availability of this provision. Funding for the latter will not be ring-fenced and may understandably not prove to be a high priority for Foundation Trusts and GP consortia during a period of radical structural change and when as providers they will be required to deliver efficiency savings over a four year time-scale on a scale that, as the Health Select Committee have pointed out, has not been achieved in the history of the NHS or by any other healthcare system in the world.

12. Developing the NHS workforce proposes that a new body, Health Education England (HEE) will provide a multi-professional oversight of the new system. The paper envisages that Medical Education England (MEE), which currently covers medicine, dentistry, pharmacy and healthcare science, will be merged with the allied health professional advisory board and the nursing and midwifery professional advisory board to create HEE. There are risks to this proposal and it would be important for HEE to ensure that the smaller allied health professions are not subsumed to the interests of medical education and the larger non-medical professions such as nursing.

13. HEE would be established as a Special Health Authority and be answerable to the Secretary of State under the terms set out for Special Health Authorities in the NHS and Social Care Bill. As a Special Health Authority, HEE would have a three year life and further primary legislation would be required (probably in 2013/14) to ensure that HEE’s existence continued in 2014/15 and beyond. However, there is no specific reference to HEE in the Bill or in the explanatory note and the Bill is silent of responsibilities in relation to workforce planning and the future education, training and professional development of NHS staff.

Local Provider Skills Networks

14. The DoH Paper further proposes that Local Provider Skills Networks should be established without specifying the governance arrangements, geographic basis or number of the latter and their relationship with HEE. It is not clear how many of these networks should or w ould operate in the future. The transfer of the current planning and commissioning function of the ten Strategic Heath Authorities to a plethora of local skills networks is a cause of further uncertainty in the future planning and commissioning of MPET / NMET provision.

15. As a legal entity HEE would be able to award contracts. However, if the Local Provider Skills Networks were also expected to commission and award contracts e.g. for NMET and allied health provision, they would have to be established as legal entities. This would be hugely costly and bureaucratic. In any case, it is difficult to see how this could be achieved prior to the abolition of the Strategic Health Authorities in April 2012. HEE itself will have to be established initially as a Shadow Special Health Authority and will be informed in the long run by the Centre for Workforce Intelligence – although the latter will not be functioning in time to inform commissions in 2012/13. Moreover, under DoH’s current proposals, HEE does not appear to have the power of direction over local skills networks to ensure that a more long term approach to workforce planning is able to influence local decisions in the future.

16. The Bill is silent on the responsibilities of providers (GP consortia and Foundation Trusts) to participate in local provider skills networks or co-operate (for example with HEE) to identify future workforce requirements. Notwithstanding the duties identified for the NHS Commissioning Board in re spect of the effective and safe delivery of services and the duty to improve quality to which the Bill refers, it is difficult to see how the DoH intends to secure effective and transparent arrangements for the future education and training of NHS staff. For its part, the NHS Commissioning Board will have a specialist commissioning budget (currently set at £20bn), 5000 staff (half the size of the current DoH) and a £400m staff and operational support budget and will have regional outposts. In principle, the Board could be given responsibility (and a commissioning budget) for the commissioning of NHS education and training. However, unless this funding was ring-fenced and a specific responsibility allocated to the Board, there would be no guarantee that this would be a priority.

17. As outlined, MPET funding currently includes NHS professional development and courses for those e.g. healthcare assistance who wish to enhance their skills. The DoH proposal to remove funding for these activities from the future MPET budget and restrict the latter to pre-registration training is at odds with the life-long learning agenda which the Coalition Government has said it values but also the quality agenda to which reference is made in the Bill. It is very unclear how well the DoH’s proposals will serve the future needs of the NHS in terms of continuous professional development and the skills training required to keep pace with developments in care and technology, improve patient care and add value in the dri v e to improve quality.

1 8 . At present, the SHAs manage MPET budgets according to national, regional and local requirements in terms of workforce planning. Universities are contracted to provide courses and have to meet certain criteria. For their part, universities plan and manage the viability of course programmes, their staffing by appropriately clinically qualified and academic staff and associated clinical placements. They are also required to meet standards and regulations set by the relevant professional health bodies and they have to match these requirements with commissioned numbers . Staff teaching MPET courses are also frequently involved in near-market research with innovative and improved outcomes in terms of products, procedures and organisational efficienc y gains in the NHS and health-related markets. The expertise of universities in England in the education and training of healthcare staff has been an area in which universities have developed international higher education partnerships, training staff in their home countries. This expertise is highly valued and these HE partnerships and contracts contribute to the UK ’s foreign exchange earnings. It is difficult to see how the DoH’s proposals to replace the commissioning functions of the SHAs will deliver value for money either within the NHS or in higher education institutions , bearing in mind their investments in clinically and academically qualified staff and teaching and research infrastructure.

19. The Public Bill Committee may therefore also wish to consider the extent to which the provisions of the Bill and the DoH’s proposals for the future award of contracts for the education, training and professional development of non-medical NHS staff are likely to contribute to the drive to achieve efficiencies within the NHS and whether these arrangements are more or less likely to increase administration, bureaucracy and q uality a ssurance requirements in both the NHS and in universities.

20. mill ion+ remains concerned that the new organisational framework envisaged in the NHS and Social Care Bill and the low level commissioning arrangements implied by the DoH White Paper will not promote effective commissioning arrangements in respect of future MPET / NMET education, training and the continuous professional development which are essential to improved patient care.

Transparency and transition

21. The NHS in England m ust have an agreed and transparent strategy for the future planning of non-medical workforce education and in particular, a mechanism for the allocation of funds for the education, training and professional development of these staff . It is essential that there is c larity in respect of funding arrangements during the transition period and also the funding arrangements that will be applied in the future. A ny new arrangements must provide for an agreement about

· the allocation of a tranche of funding for MPET / NMET in advance of the abolition of the SHAs and prior to the introduction of the new NHS organisational and funding framework

· the future allocation of MPET / NMET funding bearing in mind the requirements to make effective and efficient use of HE facilities and infrastructure and the need to avoid unnecessary bureaucracy and transaction costs within the NHS and higher education institutions .

2 2 . Experience under the previous Government illustrate s the merits of coherent and transparent funding a rrangements . For example, in 2006/07 the DoH removed the requirement for SHAs to ring-fence the MPET budget (essentially to assist SHAs to reduce deficits). This decision was made with very little consultation and without any appreciation of the implications for universities which have their own business requirements to provide viable courses and meet the quality standards laid down by the professional health regulatory bodies including in respect of staff-student ratios. Transparency and ring-fencing of MPET / NMET funding in advance of and during the transition period and thereafter, are therefore crucial.

P artnership approach

23. There would be considerable merits in DoH adopting the partnership approach currently deployed in the devolved administration s in terms of the planning and allocation of MPET student numbers . This approach already operates in respect of medical training , dentistry and pharmacy in England and will continue under the reforms proposed by the NHS and Social Care Bill. T he Scottish Funding Council (SFC) performs a similar role for medical education in Scotland . However, the SFC also manages the allocation of non-medical NHS education and training and associated numbers. These arrangements are proven, known to be workable and are administratively effective. They therefore offer a simpler and less bureaucratic system than currently operates for MPET / NMET funding in England .

24. If a similar approach in respect of the MPET budget was adopted following the transfer of responsibility from the SHAs in England, it would have the advantage of introducing a less bureaucratic system than at present while delivering transparency and an organisational framework for forward planning with HEE taking account of and mediating needs identified on a regional and local basis.

25. The adoption of a similar arrangement in England , in liaison with HEE would allow e mployer needs to be aggregated in the new NHS organisational structure and a partnership approach to be developed between employers and providers with Hefce taking on similar responsibilities to those already managed by the SFC in Scotland . Such an approach would

· ensure that a partnership approach was developed between NHS employers and HE providers

· provide for the professional bodies for MPET education and training to continue their role in maintaining quality and standards

· ensure that best use was made of expensive university infrastructure

· avoid higher transaction costs among providers .

For this partnership approach to work effectively , there would need to be

· an agreed mechanism to deliver an appropriate transfer of funds to MPET / NMET to ensure that funding was available in the transition period and prior to the implementation of any new arrangements

· an agreed and transparent mechanism for the future allocation of MPET/ NMET funding i.e. post NHS re-organisation.

26. The low-level commissioning arrangements for the future award of MPET / NMET contracts implied in the NHS and Social Care Bill and in the DoH White Paper pose real risks to NHS workforce planning and the future education and professional development of non-medical staff. Moreover, t he lack of clarity in terms of future responsibilities increases risks in respect of the viability of university-led MPET provision and the quality and scope of the education and training for NHS staff that will be available.

27. Currently, t ransitional funding and future commissioning arrangements lack transparency and the timescale for the abolition of the current commissioning bodies, the Strategic Health Authorities , is a cause of concern. It is also difficult to see how the proposed arrangements will be cost-effective , add value or improve the quality of patient care.

28. Future r e sponsibility for NHS workforce planning and the funding and commissioning arrangements for the education and professional development of NHS medical and non-medical staff should be clearly identified in the NHS and Social C are Bill.

29. Bearing in mind the proposals tabled to date, t he establishment of HEE as a Special Health Authority appears to be the best option . However, DoH must resolve the governance issues arising in respect of HEE and indicate the scale and scope of its remit and commit to appropriate funding for its staffing and operational requirements . Moreover, the Secretary of State must avoid creating arrangements in which local provider skills networks add another costly layer of bureaucracy. F uture commissioning and funding arrangements must be transparent and DoH and BIS should recognise that this is partic ularly important for universities currently engaged in contracts related to nursing, midwifery and the professions allied to health since medical numbers will continue to be allocated by Hefce.


1. Health Education England (HEE) should be established without delay as a Special Health Authority with an independent Chair and a Board that includes expertise in the commissioning of NMET and allied health professions provision and not just medical education.

2. The establishment of HEE should be underwritten and accompanied by Ministerial commitments that

(i) HEE will be provided with

(a) an agreed budget which is sufficient to meet operational support and staffing costs

(b) the authority to determine the number and geographic basis of local skills provider networks with the staffing arrangements and operational costs of the latter agreed and funded by HEE

(ii) MPET/ NMET funding will continue to include pre-registration, post registration and continuous professional development funding. This is particularly important during a period of structural change and efficiency savings and would avoid the risk of post-registration and CPD training and education being ‘lost’ during the transition period.

(iii) A tranche of funding will be transferred to HEE for the 2012/13 financial year which as a minimum, is sufficient to maintain funding and commissioned numbers, allowing for inflation and any strategic workforce planning needs identified in the 2011/12 year.

(iv) HEE will be the legal entity and will be required to work with Hefce to introduce from 2012-13 the same arrangements as currently apply to the allocation of medical education, pharmacy and dentistry, to the allocation of numbers associated with nursing, midwifery and the allied health professions. The arrangements for the alloctaion of medical and other numbers, have been proven to be administratively effective and their application to MPET / NMET numbers would provide a more efficient and less bureaucratic system for the NHS and for universitites than that which currently operates or which might be required if local provider skills networks have to be established as legal entities.

3. HEE should have a duty to establish effective local skills provider networks or alternative organisational arrangements to ensure that HEE is informed by local workforce needs as well as by the Centre for Workforce Intelligence.

4. Quality assurance arrangements in respect of NHS educational provision should be provided through the professional bodies which would continue to be required to give course approval.

5. At a time of significant reform in both health and higher education, these recommendations are likely to ensure continuity in NHS workforce planning, education and training, offer real benefits in terms of transparency and administrative efficiency in the commissioning process, provide a mechanism for the latter to be informed by and responsive to local provider needs and provide arrangements to mediate these needs against nationally agreed workforce requirements.

However, in order to avoid further uncertainty, the Secretary of State and Government Ministers from DoH and BIS should confirm their intention to implement these recommendations and the associated funding requirements as soon as possible during the Committee stage / the passage of the NHS and Social Care Bill through Parliament.

March 2011

[1] In Scotland, Wales and Northern Ireland, funding is allocated by the individual education funding bodies in the respective nations and devolved administrations for the same areas of professional education and training e.g. in Scotland MPET student numbers are allocated by the Scottish Funding Council.