8 Health Education England |
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.
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.
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."
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
Health care and social care
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
. the view that it should not have a primary
social care focus has generally been supported by stakeholders."
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."
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
To describe all these as "care workers", especially
in this particular draft Bill, strikes us as misleading.
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".
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.
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
Medical training of managers
5% of NHS chief executives are doctors, and only 15% are clinicians
of any sort.
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
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.
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."
He invited us to make recommendations to have something more explicit
in the draft Bill.
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 staffespecially those without degree-level qualificationsswitch
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.
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.
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 LETBsto take
a view about whether that feels helpful."
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."
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.
When, as we were told, the training of a consultant neurosurgeon
can take up to 20 years,
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
The wider picture
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."
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 doto
go and spend part of their careers working overseas. But that
did not have a particular impact on the NHS."
An over-supply of staff
problems caused by a shortage of staff are plain.
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."
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
been concerns that there may be a potential oversupply of
doctorsnewly qualified medical graduatescoming 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."
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
will take account of the balance between generalism and specialism."
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
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
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
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."
large number of our witnesses criticised the words "have
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."
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.
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
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.
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.
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
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.
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.
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 "
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
Q 264. Back
Q 27. Back
Section 1F(1) of the National Health Services Act 2006, inserted
by section 1(7) of the Health and Social Care Act 2012. Back
Professor Cumming, Q 266. Back
Q 66. Back
The Foundation NLC Annual Report - First Year: executive summary,
National Leadership Council, page 9, cited in paragraph 24.27
of the Francis Report. Back
Q 347. Back
Q 343. Back
Q 349. Back
Q 279. Back
Q 279. Back
Professor Cumming, Q 267. Back
Q 278. Back
Q 348. Back
The Royal College of Midwives report that there is currently a
shortage of about 5,000 midwives: see the question from Baroness
Cumberlege and the reply by Earl Howe, Parliamentary Under-Secretary
of State at the Department of Health, House of Lords Official
Report, 25 February 2013, columns 846-848. Back
Professor Cumming, Q 280. Back
Q 348. Back
Q 307. Back
Q 308. Back
Q 280. Back
Q 305. Back
Q 345. Back
Q 269. Back