Draft Care and Support Bill - Joint Committee on the Draft Care and Support Bill

Draft Care and Support Bill - Joint Committee on the Draft Care and Support Bill Contents

8 Health Education England

Background

293. Less than a year ago the Secretary of State used his powers under section 28 of the National Health Service Act 2006 to set up Health Education England (HEE) as a Special Health Authority. The Authority's function was to exercise the Secretary of State's duties relating to the planning and delivery of education and training to persons employed, or considering becoming employed, in the delivery of services as part of the health service in England.[228] Chapter 1 of Part 2 of the draft Bill will now formally constitute HEE as a non-departmental public body with its constitution and functions set out in statute. This conversion of HEE from a Special Health Authority into an NDPB was welcomed by our witnesses.

294. Sir Keith Pearson, the Chair of HEE, told us that the NHS employs about 1.3 million people. "We underpin that with training, education and continuous professional development. At any one time there are about 160,000 people in undergraduate or postgraduate education, so there are a fair number of people who are being supported through education."[229]

295. HEE, as its name implies, has responsibilities for England but not for other parts of the United Kingdom. At local level HEE establishes Local Education and Training Boards (LETBs), together covering the whole of England, as Committees of HEE, to help HEE in carrying out its planning, education and training functions in their respective areas.

Health care and social care

296. It would have been possible to give HEE responsibilities for social care, but Jamie Rentoul, the Director for Workforce Development at the Department of Health, told us: "The view of Ministers at that stage was that it should focus on health and public health, with a particular focus on essentially future-proofing the health and healthcare workforce in terms of the development of health professionals, …. the view that it should not have a primary social care focus has generally been supported by stakeholders."[230]

297. This has led to a problem of terminology. The primary function of HEE is the education and training of "care workers", an expression which, in a draft Bill whose main concern is social care, might be taken to include care workers other than health care workers. The expression "care worker" is defined in clause 55(9) by reference to a provision setting out the persons in relation to whom the Secretary of State has responsibilities for education and training, viz "persons who are employed, or who are considering becoming employed, in any activity which involves or is connected with the delivery of services as part of the health service in England."[231] Such persons embrace medical students and senior hospital consultants, taking in nurses, healthcare assistants and hospital porters; "a chief executive and a finance director are healthcare workers."[232] To describe all these as "care workers", especially in this particular draft Bill, strikes us as misleading.

298. We are not alone in that view. Professor Cumming, the Chief Executive of HEE, told us: "I personally do not think the term "care worker" is the right one. I think what we refer to is "health and healthcare workers", because, of course, we have the public-health people as well who are not healthcare. The way we describe the people we interact with is "health and healthcare".[233] It seems to us that a more accurate and less misleading way should be found to describe the group of persons for whose education and training HEE has responsibility.

299. We recommend that the persons for whom HEE has education and training responsibilities should not be described in this Part of the draft Bill as "care workers", but that some other generic description should be found, such as "health and care sector staff".

Medical training of managers

300. Only 5% of NHS chief executives are doctors, and only 15% are clinicians of any sort.[234] This country used to have officials with the title of "medical superintendent" who had medical training and, sometimes, medical experience, but acted in a managerial capacity. We suggested to Dr Daniel Poulter MP, the Parliamentary Under-Secretary of State at the Department of Health, that it would be valuable if some senior managers, whatever their title, had some medical knowledge and experience. He described this as "an excellent suggestion".[235]

301. HEE should certainly encourage a greater proportion of future managers to have clinical experience. However the development of NHS leaders is the responsibility, not of HEE, but of the NHS Leadership Academy, which leads the process of commissioning leadership development. It is not clear to us how the two bodies will work together. It should be a statutory requirement for HEE to work in partnership with the NHS Leadership Academy to ensure that managers in their training learn alongside their clinical colleagues, with a specific objective of ensuring that a greater proportion of the managers of the future have clinical experience.

Integration

302. We suggested to Dr Poulter that it might be useful to insert in the draft Bill a duty for HEE to promote and support education and training of people so that they could work either in the health care or the social care sector. Dr Poulter conceded that we would needed an increasingly multidisciplinary workforce that worked across both health and social care. He told us: "Unless that is embraced and made a priority for HEE, which we feel we are certainly doing through the mandate, then that will not become a reality. It is about breaking down silo working; it is about making sure that there is a clear recognition that, in an age where we want to provide more care in the community, we need a more mobile workforce that can work across different care settings. As you rightly highlight, that needs to be reflected in the clear instructions given to HEE."[236] He invited us to make recommendations to have something more explicit in the draft Bill.

303. Making HEE responsible for the education and training of social care staff may be a bridge too far for this legislation. However we consider that the draft Bill should be amended to reflect better the Minister's evidence and the growing need to recognise that many care staff—especially those without degree-level qualifications—switch between and work across health and care and support settings. In doing so they are often doing similar jobs of looking after people at times of great vulnerability that require the same skills, training and compassion. This needs to be reflected in the education and training programmes and qualifications resulting from the work of HEE and LETBs.

304. Clause 59 lists seven matters to which HEE must have regard in setting priorities and outcomes for education and training. We recommend adding to that list (a) the promotion of integration (including between health and care and support) to align HEE with the duties placed on the NHS Commissioning Board and Clinical Commissioning Groups, and (b) the desirability of enabling people to switch between and work across a range of different health and care and support settings.

Long-term planning

305. Clause 56 requires HEE to ensure that a "sufficient number of persons with the skills and training to act as care workers for the purposes of the health service is available to do so throughout England"; the LETBs help in carrying out this function at a local level. Clause 58 in effect requires HEE to publish a forward plan, and to revise and re-publish it every year. There is nothing to say how far ahead this forward plan should look. Jamie Rentoul explained that in clause 58: "… we did not want to say it was three, five or 10 years in primary legislation, because we felt HEE should be considering it, and there is a further subclause that says, 'And it can vary the period of time for different care workers.' We are trying to say we do want HEE to take a strategic view, building off the mandate it will get from ministers. It needs to thinks about what is sensible. In moving to the new system now, we have said fiveyear plans from LETBs—to take a view about whether that feels helpful."[237]

306. We agree with Professor Cumming when he said: "I certainly would not want to see us producing one year workforce plans. They are not worth the paper they are written on for anybody. They have to be longer term."[238] Unlike Mr Rentoul, we believe that primary legislation should specify the minimum term for a long-term plan. Professor Jessica Corner, the Vice-Chair of the Council of Deans of Health, speaking about the plans of LETBs, thought a five-year plan might be appropriate.[239] When, as we were told, the training of a consultant neurosurgeon can take up to 20 years,[240] we believe that five years should be a minimum for HEE's own forward planning. Clause 58(3) should be amended to make clear that, in setting out its forward plans, HEE should include one plan looking at least five years ahead, and preferably longer, and that it should be updated annually. LETBs should have a similar requirement.

The wider picture

307. HEE, though its direct responsibilities are limited to England, cannot act without cooperating closely with the bodies with similar responsibilities for Wales, Scotland and Northern Ireland, given the flow of personnel across the borders. It also has to be aware of and act upon global developments. Professor Cumming told us that staff at the GMC had been very busy processing applications from Greek and Spanish nationals wanting to join the UK medical register because of economic conditions in Greece and Spain. "So as well as producing workforce plans, which have to look many years ahead into the future, we have to be able to respond to events and move fairly quickly if we see something happening. With Obamacare in the USA, I believe that there is a high risk we are going to lose well-trained nurses to the US, because they need to increase the number of nurses they have relatively quickly. We are going to have to respond very quickly if that becomes a problem, or we will end up with a shortage of nurses in our healthcare system in this country."[241] However Dr Poulter was less concerned: "In terms of the Obamacare issue, we had the same discussion a few years ago when Australia and New Zealand were actively advertising and trying to recruit British nurses to go over to Australia and New Zealand. Some nurses, as doctors do now, may go over for two or three years to go and work there; it is something that young people tend to do—to go and spend part of their careers working overseas. But that did not have a particular impact on the NHS."[242]

An over-supply of staff

308. The problems caused by a shortage of staff are plain.[243] Less plain are the difficulties, mainly of cost, if more staff are trained than are needed. "We cannot afford, and should not have, a large number of unemployed doctors, dentists, nurses, pharmacists or whatever it may be. …. It is absolutely critical that we get this right and I would not have a problem at all if the Bill were strengthened in that way."[244] But cost is not the only factor. Dr Poulter said: "I believe we have a moral duty to make sure that, when medical graduates leave medical school, they are fully signed up … There have been concerns that there may be a potential oversupply of doctors—newly qualified medical graduates—coming out of medical school compared with places on foundation programmes. That is not just this year; it has been for a number of years. …. in Wales there is an oversupply, and in Scotland a slight over-supply, of graduates compared with jobs. That is why we have to work across the UK to make this a reality."[245]

309. There also has to be a balance within the professions. Anecdotally, we were told that 60% of medical students on their first day at university aspire to be surgeons. Fewer than 10% will end up as surgeons; the great majority will become GPs. Sir John Tooke, the President of the Academy of Medical Sciences, explained that "All doctors are going to have to be able to cope with multiple comorbidities rather than seeing themselves as a highly specific specialist, except in exceptional cases … true matching will take account of the balance between generalism and specialism."[246]And Professor Norman Williams, the President of the Royal College of Surgeons, told us that "surgery and the medical specialities are very exercised about the overproduction of superspecialists.[247]

310. Clause 56 of the draft Bill is entitled "Ensuring sufficient skilled care workers for the health service" and, as we have said, requires HEE only to ensure that there are "a sufficient number of persons … to work as care workers". Regulations under clause 56(2) may provide that this duty "is exercisable only, or is not exercisable, in relation to persons of a specified description".[248] That seems to us inadequate; it still will not deal with the question of over-supply. Professor Cumming expected that HEE would be "held to account on an annual basis for making sure that, as far as possible, supply and demand are in equilibrium." We agree that this is essential. Clause 56 must be amended to make clear that the duty of HEE is not merely to ensure a sufficiency of skilled workers, but to ensure that supply and demand are as far as possible matched, not just overall, but within each group of "persons of a specified description".

Clause 57: the duty to promote research

311. Clause 57(2) reads: "HEE must, in exercising its functions, have regard to—(a) the need to promote research into matters relating to the activities listed in section 63(2) of the Health Services and Public Health Act 1968 (social care services, primary care services and other health services); (b) the need to promote the use in those activities of evidence obtained from the research."

312. A large number of our witnesses criticised the words "have regard to … the need to promote research" as being far too weak. They included some of the Royal Colleges, research organisations, and HEE itself. In oral evidence Sir John Tooke told us that "the key issue from the Academy of Medical Sciences' perspective is that we need to strengthen the statement that HEE should 'have regard to the need to promote research' to actually 'promote research'. I say that not simply as somebody who clearly has an interest in seeing research flourish in the UK. It is because of the requirement for the NHS to become far more research aware if it is going to develop the critical culture and transformative capacity it needs to respond to health challenges."[249]

313. The Wellcome Trust was emphatic in its written evidence: "We consider the duty for HEE to 'have regard to the need to promote' research and the use of research evidence (clause 57(2)) to be far too weak. As drafted this duty is too ambiguous and fails to commit HEE to action, therefore this duty must be strengthened simply to 'promote'. This change would recognise the important role that HEE must play in championing research. … In order to ensure that new technologies such as genomics and stratified medicines are deployed effectively in the NHS, it is essential that healthcare professionals are given the education, training, time and resources needed to support research and innovation. HEE must ensure that this is the case …".

314. Sections 6, 23 and 26 of the Health and Social Services Act 2012 insert into the National Health Service Act 2006 provisions which impose on, respectively, the Secretary of State, the NHS Commissioning Board and Clinical Commissioning Groups a duty to "promote research on matters relevant to the health service". Dr Poulter reminded us that the Bill for that Act had originally read "have regard to the need to promote research," and that this had been changed in Committee to make the duty more explicit.[250] The Wellcome Trust and the Royal College of Surgeons both told us in their written evidence that the duties of HEE should be brought into line. We agree.

315. Clause 57(2) should be amended so that HEE has, like the Secretary of State, the NHS Commissioning Board, and Clinical Commissioning Groups, a duty to promote research on matters relevant to the health service. In the case of HEE this duty should extend to the other matters listed in paragraph (a), which include social care services.

Commissioning research

316. Professor Cumming suggested to us that, in addition to promoting research, HEE should have the power to commission research into matters relating to its own activities of education and training.[251] We see force in this, and are surprised that HEE does not already have this power. Clause 60 requires HEE to seek advice on the exercise of its functions from persons involved in or interested in education and training for care workers. We recommend that clause 60 should be broadened to allow HEE's obligation to obtain advice to include the commissioning of research on the exercise of its functions.

Safeguarding

317. The Francis Inquiry report published during our inquiry makes a great many recommendations. In his letter to the Secretary of State, Robert Francis QC says that there is a need to "… enhance the recruitment, education, training and support of all the key contributors to the provision of healthcare, but in particular those in nursing and leadership positions, to integrate the essential shared values of the common culture into everything they do". He goes on to makes 21 recommendations related to education and training. Most of these are directed towards the Government and the General Medical Council. During our evidence session with the Minister we raised with him the fact that neither in the draft clauses nor in Schedule 5 is there any explicit reference to HEE having duties relating to safeguarding. The Government should consider amending the draft Bill to give both HEE and LETBs a duty to ensure that the principles and practice of safeguarding are integral to education and training.

228 The Health Education England (Establishment and Constitution) Order 2012, SI 2012/1273, which entered into force on 28 June 2012. Back

229 Q 264. Back

230 Q 27. Back

231 Section 1F(1) of the National Health Services Act 2006, inserted by section 1(7) of the Health and Social Care Act 2012. Back

232 Professor Cumming, Q 266. Back

233 Q 66. Back

234 The Foundation NLC Annual Report - First Year: executive summary, National Leadership Council, page 9, cited in paragraph 24.27 of the Francis Report. Back

235 Q 347. Back

236 Q 343. Back

237 Q 349. Back

238 Q 279. Back

239 Q 279. Back