The Long-term Sustainability of the NHS and Adult Social Care Contents

Chapter 3: Workforce

103.Those who work in the NHS and adult social care are the lifeblood of the organisations they serve. The NHS is dependent on a reliable supply of appropriately skilled and highly motivated individuals to meet the ever increasing demand for care. The NHS website described the scale of the current workforce of the NHS in England as follows:

“The NHS employs more than 1.5 million people, putting it in the top five of the world’s largest workforces … The NHS in England is the biggest part of the system by far, catering to a population of 54.3 million and employing around 1.2 million people.”72

It is estimated that some two-thirds of the health service budget goes on salaries and wages for staff.73 However, the Association of Directors of Adult Social Services (ADASS) reminded us that there are more employed in adult social care than there are in the NHS.74

104.Changing models of care require a flexible workforce that can adapt to new ways of working, but appropriate training and a healthy morale are critical if this workforce of the future is to be delivered. This chapter will look at issues such as planning, skill mix and training and the relationship between regulation, pay and morale.

Workforce strategy

The aspiration

105.Like any large organisation, workforce planning in the NHS is critical. The length of time and investment required to educate certain medical professionals means that this planning must take place over a long timeframe. An accurate estimation of future demand is also important. The Five Year Forward View summarises this critical requirement:

“Health care depends on people—nurses, porters, consultants and receptionists, scientists and therapists and many others. We can design innovative new care models, but they simply won’t become a reality unless we have a workforce with the right numbers, skills, values and behaviours to deliver it.”75

106.The content relating to workforce in the Five Year Forward View is a positive step forward and the leadership shown by the Chief Executive of NHS England, Simon Stevens, should be applauded in this regard. The document speaks of moving away from a more specialised workforce towards a more holistic clinical approach and the need to move to more community-based working. It also acknowledges the need to plug the skills gap in the workforce, to invest more in training and to help employees work across organisational and sector boundaries. Future-proofing the workforce is also highlighted and the Five Year Forward View references the Shape of Training Review76 for the medical profession and the Shape of Caring Review77 for nursing, both of which sought to reform the way in which the workforce is trained.

A sound evidence base

107.A robust evidence base projecting future demand is required if workforce planning is to be carried out in a reliable manner. Gavin Larner, Director of Workforce at the Department of Health, described a piece of work called Horizon 203578 which was commissioned by the Department. He outlined the work of the project as follows:

“It has been trying to extend the global factors … to see what the position will look like in the mid-2030s. A team of economists has been looking quite carefully at the evidence base. It concludes that, with the ageing population and the further spread of chronic disease through all age groups—beyond just older age groups—an estimated 3 billion extra care hours will be needed by 2035 and demand for care could rise twice as fast as population by that time. Its conclusion based on that is that you will need a lot more [lower paid staff] than we currently have, to cope … “79

108.The challenges posed by this demographic trend are well understood and reliable data to illustrate the ageing population is readily available, as described in Chapter 2. However, despite this, we were told that no workforce costings associated with this demographic trend had been calculated.80 This compartmentalised and silo-thinking mentality emerged as a general theme from the evidence we received. The move to a unified vision for the medium-term in the Five Year Forward View was, undoubtedly, a positive development when it was published in 2014. But from the evidence we received, a longer-term, centralised strategy which joined-up workforce planning with other challenges faced by the NHS, such as financial sustainability and the adoption of new technologies, for example, appeared to be absent. In fact, we received no evidence to suggest that workforce planning was linked to financial planning in any meaningful way at all. This appeared to be because longer-term financial planning or service planning was not taking place at all or because there were conflicting interests within the bodies controlling the limited workforce planning that was taking place.81 For example, there was a clear conflict between the desire of Health Education England (HEE) to educate and train more staff and the opposing objective of NHS Improvement to seek cost reductions wherever possible.

Health Education England

109.HEE is a non-departmental public body and its website describes its core purpose as follows:

“Health Education England (HEE) exists for one reason only: to support the delivery of excellent healthcare and health improvement to the patients and public of England by ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviours, at the right time and in the right place.”82

110.Professor Ian Cumming, Chief Executive of HEE, told us about the importance of joined-up planning:

“… you need to make sure the service and workforce planning are properly joined-up, so we need commissioners’ intentions aligned with those who will be delivering the service, aligned with workforce planning. We also need to recognise that workforce planning has to be a very long-term strategy … Of course, medical students entering university this year will become consultants in about 13 to 15 years, so the plans we are making at the moment on the numbers entering medical school will not have an impact on the workforce until 2030–31. We have produced a document called Framework 15, which takes a 15-year forward look, specifically designed around the medical workforce, to ask what we believe patients’ needs will be in 15 years’ time, and how we make sure that we are training doctors and other healthcare professionals to work in that timescale and not training people to work in the health service that we have today—because it will look very different.”83

111.The evidence we received outlining the ongoing work within HEE was encouraging, but we were not presented with any examples of the body being able to influence a shift in the allocation of financial resources to make workforce planning a reality, or any evidence that the Department of Health was providing leadership in this area. Indeed, instead of workforce planning which was based on sound demographic data driving expenditure, short-term thinking seemed to be a real driver of supply. The Government frequently repeat that they have secured 9,500 more doctors and 6,900 more nurses since 2010, a flagship feature of the 2015 Conservative Party Manifesto,84 but there is no evidence to suggest that these numbers were agreed to meet an identified demand based on specific demographic data or calculations. Dr Sarah Wollaston MP, the Chair of the House of Commons Health Select Committee, was disappointed to note that HEE’s budget had been cut in real terms, and we echo this sentiment.85

112.The failure to prioritise workforce planning can result in gaps in the current workforce. Candace Imison, Director of Policy at the Nuffield Trust, told us that if this trend continued “there will be very obvious gaps in the medical workforce.”86 The Royal College of Physicians told us of the increasing prevalence of consultants covering gaps in trainee rotas and that “together with a shortage of nurses, this has left our hospitals chronically understaffed. This increases pressure on NHS staff, impeding morale and puts patient care at risk.”87 According to Mind, almost half of community mental health teams had staffing levels judged to be less than adequate in 2013–14.88 The Royal College of Midwives told us that they have:

“… used the Birthrate Plus methodology to assess the adequacy of the size of the midwifery workforce; our current assessment is that midwifery services in England are 3,500 [whole time equivalent] midwives short of what would be needed to ensure that every woman could receive 1:1 midwifery care in labour, as clinically recommended.”89

Workforce gaps are clearly a continuing case for concern, both in the NHS and in the adult social care sector. Skills for Care is an independent charity in receipt of public funds which is largely responsible for supporting organisations to develop their adult social care workforce in England. Care England argued that HEE should be given a role in social care workforce planning too: “In order to protect long-term NHS sustainability, HEE must start planning for the social care workforce now … “90

Overseas workers and Brexit

113.The NHS and social care workforce draws on global talent and relies on a steady stream of immigration. The Recruitment and Employment Confederation told us that:

“The latest data from the Health and Social Care Information Centre (June 2016) reports that 57,608 staff employed in NHS Trusts and Clinical Commissioning Groups in England declare their nationality to be from a European Union member state—71,510 staff are from non-EU member states; collectively accounting for around 11% of all staff … A similar picture is found in social care—Skills for Care (2015): The State of the Adult Social Care Sector and Workforce in England—reports that 5% of adult social care staff are from EU countries and 11% are from non-EU countries.”91

114.Because of the long-established dependence on overseas recruitment, there was considerable anxiety expressed about the impact of the United Kingdom’s exit from the European Union and the prospect of tighter immigration rules.92 There is a strong case in the short term for the Government to do all it can to reassure those who may be affected by the United Kingdom’s exit from the European Union to mitigate against an exodus of overseas workers. In the longer term, the Government should go to greater lengths to secure a reliable supply of well-trained professionals and other health and social care workers from within this country.

115.Professor Ian Cumming told us about the reliance on overseas workers:

“From our perspective, we believe that, as the fifth-largest economy in the world, we have a moral duty to produce the healthcare workforce that we require for our National Health Service, and we should not be reliant on recruiting from other countries. That is absolutely not the same as saying that we do not welcome the opportunity for people from other countries to come and learn here and work with us.”93

116.Independent Age called on the Government to ensure that all EEA migrants currently working in social care in the UK had the right to remain post-Brexit and that any future migrant social care workers were appropriately recognised in any new approach to migration. They outlined the potential consequences of a workforce gap in the social care sector:

“The implications of a social care workforce gap of between 350,000 and 1.1 million workers for older and disabled people are clear—far fewer will be able to access the care they need to live meaningful, independent lives.”94

117.We were encouraged that this aspiration was expressed by the Secretary of State for Health:

“I would say that workforce planning is an area where we have failed, and successive governments have failed to get this right. Brexit will be a catalyst to get this right, because we are going to be standing on our own two feet and we will have to start thinking much harder without the automatic access to the European labour pool that we have taken for granted for many years. That is an area where we need to be much more strategic than we have been. Being able to announce 1,500 medical places is only a start, but that was four months after the Brexit vote. I think that shows there is a serious effort going into being more strategic in our workforce planning, but there is lots more to do.”95

118.He also said:

“… if, as I suggest to you, over the coming decades we will need to spend a greater proportion of our GDP on health and social care, we will need more doctors and nurses. Doctors take six years to train and nurses take three years to train, and we need to start thinking about that now, because the truth is, even while we are in the EU and we can import as many doctors and nurses as we wish from EU countries without restrictions, we still have rota gaps; we still cannot find enough of them, because every country is facing the same problem. One of the most important reasons for taking a longer-term view is to be able to be more strategic about our workforce planning.”96

119.We are concerned by the absence of any comprehensive national long-term strategy to secure the appropriately skilled, well-trained and committed workforce that the health and care system will need over the next 1015 years. In our view this represents the biggest internal threat to the sustainability of the NHS. Much of the work being carried out to reshape the workforce is fragmented across different bodies with little strategic direction from the Department of Health. Although we recognise that Health Education England has undertaken some work looking at long-term planning for the workforce, this is clearly not enough. Health Education England has been unable to deliver.

120.We recommend that, as a matter of urgency, the Government acknowledges the shortcomings of current workforce planning. Health Education England, both nationally and through the network of local education and training boards, should be substantially strengthened and transformed into a new single, integrated strategic workforce planning body for health and social care. This will enable it to produce and implement a joined-up place-based national strategy for the health and social care workforce, and it should always look 10 years ahead, on a rolling basis. Consideration should be given to its name to better reflect its revised function.

121.Health Education England’s independence should be guaranteed and supported by a protected budget with greater budgetary freedom. It will need enhanced skills and a board that includes representation from all parts of the health and care system.

122.Workforce strategy has been poor with too much reliance on overseas recruitment. The Government should outline its strategy for ensuring that a greater proportion of the health and care workforce comes from the domestic labour market and should report on progress against this target.

123.In the light of the result of the EU referendum, we recommend that the Government takes steps to reassure and retain overseas-trained staff working in the NHS and adult social care who are now understandably concerned about their future.

Skill mix and training

Skill mix and evolving roles

124.Securing the right numbers of staff is not enough. Appropriately trained and skilled individuals are critical and, from the evidence we heard, there was broad agreement that more needed to be done to improve the education and training of the current workforce. Striking this balance between investing in a new workforce and developing the current workforce will be key. As we noted above with disappointment, the body charged with responsibility for this, HEE, has had its underlying budget cut in real terms.97 The figures announced in the 2015 Spending Review redefined NHS spending, from what used to be the totality of the Department of Health’s budget to mean NHS England’s budget only. Other health spending not included in NHS England’s budget—for example, spending on public health, education and training—was excluded. As The King’s Fund, the Nuffield Trust and the Health Foundation said at the time, HEE’s budget was likely to be frozen in real terms.98

125.The way in which the workforce is trained has a direct impact on the way it functions. When questioned about the length of time it currently takes to train certain medical professionals, Professor Wendy Reid, Director of Education and Quality at HEE, spoke about work associated with the Shape of Training Review.99 We heard from Dell EMC that some education providers required individuals to repeat training they had already completed elsewhere.100 A number of organisations also highlighted the serious challenge posed by high attrition rates for trainee medical professionals.101 We were, therefore, pleased to hear that NHS Improvement was planning to conduct a review of the drivers of medical workforce attrition and how retention in general could be improved.102 There is also a strong case for appealing to those who have already left the workforce to return.

126.Overall, however, we were unconvinced that HEE’s work with the Royal Colleges, higher education providers and others involved in influencing the way in which the workforce is educated and continually trained was persuasive or strong enough and, from the evidence they provided, we were disappointed that they were not displaying a clear lead on radically changing the way the medical workforce is educated and trained.103

127.We heard consistently that there was a skill mix problem with the current workforce. There was a broad recognition that the workforce of 2030 would need be different—that the skill mix would need to change—and some agreement that the NHS needed to get the balance right between generalists and specialists. Witnesses also highlighted that, in part, the workforce of 2030 was already in operation. Professor Ian Cumming told us that:

“… the majority of people who will be working for the NHS in 20 years’ time are in employment at the moment, so more than 50% of the people who we will have delivering care are actually our current employees. One mistake that we must not make is just to focus on the future workforce, and people coming through the education and training system. If we are to deliver transformation, we must focus on the people whom we currently employ, and I do not think we have given that enough attention. That is why perhaps the pace of change has not been as quick as we would like it to be.”104

128.Candace Imison, Director of Policy at the Nuffield Trust, described the current situation:

“The point I would like to get across about future sustainability to leave in the Committee’s heads is the degree of skills mismatch that we currently have in the workforce. A very powerful study was done across the whole OECD that showed that 51% of doctors and 43% of nurses felt they were underskilled for what they are currently doing, whilst 76% of doctors and 79% of nurses felt that elements of their role were overskilled. That tells us that our roles are not designed correctly for the skills of the staff that sit within them.”105

129.Without sufficient flexibility, the way in which the workforce is educated and trained can limit the type of roles they are able to perform. Consequently, there were calls for greater flexibility and mobility between specialties in medicine and between different types of health care professionals, including the allied health professions. Richard Murray, Director of Policy at The King’s Fund, spoke about the challenges and opportunities created by new roles emerging within the workforce:

“The challenges as you look out into the future, alongside the demand and affordability piece, are particularly around new roles. We have an old model of consultants, nurses and more junior staff. As you look out—particularly reflecting the changing demographic needs of the population—is that appropriate? It is very difficult for a planner to know now, as some of the roles are nascent roles that are not with us yet.”106

130.Ian Eardley, Vice-President of the Royal College of Surgeons, also pointed out the opportunity presented by new non-medical roles and suggested that the NHS needed to “take a longer-term view on workforce planning with a potentially increased role for a non-medical workforce to provide medical and social care.”107 Professor Cathy Warwick, Chief Executive of the Royal College of Midwives, whilst acknowledging the proper role of medically trained professionals, argued that support roles were crucial:

“From my point of view, the greatest threat to maternity services is not having enough midwives. We now know from global research that if you are going to maintain the health and well-being of women and babies, they need midwifery input, and that is best delivered by midwives. It is not protectionism. The fact is that investing in midwives leads to higher-quality care. However, I would add that those midwives need to be well supported by highly qualified, well-trained, competent maternity support workers, and we need to focus on that workforce as well and help them reach the required standard. We also need to ensure that our maternity services have sufficient clerical support. Midwives are currently spending up to 50% of their time doing non-clinical duties, and that is absolutely shocking.”108

We wholeheartedly endorse this view and would encourage all those in the health and care system to embrace the opportunities for different ways of working made possible by emerging workforce and support roles.

131.Natalie Beswetherick, Director of Practice & Development at the Chartered Society of Physiotherapy, saw these new roles as key to the sustainability of the workforce and told us that the Government must be held to account for its promise to deliver more of these new roles:

“… we need national accountability for the 10,000 workforce expansion for allied health professionals and nurses that was made in the last comprehensive spending review, and at the moment there is no accountability to deliver that. Without that workforce across allied health professions and nurses, we will not be able to get that sustainability in future.”109

132.New roles can bring new challenges and require people to adapt the way they work. Gavin Larner, Director of Workforce at the Department of Health, told us about the reticence on the part of some to fully embrace these new roles:

“… there are strong culturally conservative parts of our healthcare system, where the different professional tribes see particular ways of delivering services. That is not necessarily always a self-regarding thing—it can be a genuine concern about what they feel is the best place to deliver the safest care.”110

133.Professor Sir John Bell, Regius Professor of Medicine at the University of Oxford, echoed this point:

“I am sorry to say the workforce in the healthcare system is hugely, in a sense, unionised; they are deeply conservative; they do not want to change what they do; they are dug in … it is this heavily—”unionised” is probably the wrong word—consolidated view of healthcare workers who form groups and tribes within a healthcare system where they defend each other, defend their space, and they do not want to change. Worse than that, we train people to be highly focused on doing one thing and if we want them to be doing something else later in their careers, they will fight for their lives to stay doing what they were doing, even though we all know it is not cost-effective, so it is a real issue.”111

We are clear that the current situation is totally unacceptable and will fail to deliver the services that patients will need in the future. This should be a major concern for all those working in the health service and those who represent them. The conservative culture which exists in some quarters should be challenged by political, professional and managerial leaders.

134.A transformed Health Education England should use its greater budgetary freedom to review current commissioning and funding mechanisms to explore how initial and ongoing education and training might achieve a more multi-professional skill mix among the workforce and be underpinned by a place-based approach.

135.There has been too great a reluctance by successive governments to address the changing skill mix required to respond to a changing patient population and too little attention paid to workforce planning, education and training, all of which are necessary for delivering efficiency, productivity and overall value for money.

136.Health Education England should take the lead on changing the culture of conservatism which prevails among those who educate and train the health and social care workforce. It should convene a forum of the Royal Colleges, the General Medical Council, the Nursing and Midwifery Council, higher education institutions, other education providers, social care providers and local government representatives to investigate how medical and social care education and ongoing training courses can be reformed. Many are too lengthy, involve unnecessary repetition and do not meet the needs of a workforce which will have to be more flexible, agile and responsive to changing need.

137.Given the move to a more localised and place-based approach to the provision of health and social care, a more flexible approach to the make-up of the workforce is required. Professional bodies, education providers and regulators should embrace the opportunities for different ways of working made possible by emerging, often non-medical, workforce roles and should not be afraid of challenging the traditional allocation of responsibilities within professions.

Regulation, morale and pay

The role of regulation

138.Health and care provided through the NHS is regulated by two system regulators and nine main professional regulators.112 We heard a great deal about the impact of over-burdensome regulation—both systemic and professional—on workforce morale and retention. The evidence we received suggested that out-of-date professional regulation hampered the development of new practitioners such as nurse associates and physician assistants, and that an overly interventionist approach to regulation was creating an unnecessary and restrictive administrative burden on other clinicians.

139.Professor Sir Mike Richards, Chief Inspector of Hospitals at the CQC, told us that the work of the CQC was more valued than one might expect. He admitted, however, that things needed to change:

“… even among general practitioners, going back to the question of whether we get good or bad press, 57% of them say that it has been beneficial and had a good impact, so it is not all that you may hear. What we will do at the end of our first round is look at the whole process of how we do general practice inspection. We have set out our new strategy overall for the CQC, which includes having a more targeted and tailored approach … we will need to be lighter on our feet and we will need to target those places where the problems are greatest, but we will adapt so that we can inspect and regulate new models of care. With those new models of care, we are saying, ‘Please tell us what you are planning so that we can plan the regulation with you.’”113

This approach is encouraging. It is our view that system regulators need to adapt to changing ways of working and develop the ability to engage with place-based care and not simply with fixed institutions and bodies. System regulators should be willing to adapt to the present reality of the way in which health and care is delivered.

140.Dr Clare Gerada, General Practitioner and former Chair of the Royal College of General Practitioners, told us about the effects of the Health and Social Care Act 2012:

“We live in a bureaucratic jungle. It is terrible. Every single day is full of box-ticking and reporting. Even I do not now know what I am meant to do. I discovered the other day that I have not done my heavy lifting training, which will make me non-CQC-compliant. I have to go and do it. It is dreadful in there. It certainly has not released us from the bureaucratic nightmare.”114

In fact, Professor Maureen Baker, former Chair of the Royal College of General Practitioners, argued that in recent years she had actually seen an increase in bureaucracy.115

141.A solution was proposed by Baroness Cavendish of Little Venice:

“One thing that could be done from the centre which is very simple, which I am always going on about, is to reduce bureaucracy. The amount of paperwork and pressure put on the front line by central government and the whole of this landscape of quangos is utterly unacceptable. I find that people in the centre of government or in the quangos have no understanding of that, have no overview of how the amount of data they require overlaps with the amount of data other people require. Other people have recommended endlessly that we need one single data set that should be required by all of these public agencies from all of these providers, whether they are in health or social care. I am not saying that that is the answer but I think you would find productivity would increase dramatically.”116

142.It is clear to us that such a simple development would radically change the workload of those struggling to comply with the many overlapping and competing requirements of different regulators. In a letter to the Chairman dated 15 February 2017, the Chief Executive of the CQC, Sir David Behan, told us that they intended to take steps to alleviate the pressure of regulation. These steps would include, among other things, reducing duplication, requiring only one data return from GPs and reducing the frequency of inspections for those GP practices rated good and outstanding.117 This was welcome news and we look forward to seeing these changes implemented.

143.Another proposal was to reduce the number of regulators. Professor Dame Sue Bailey, Chair of the Academy of Medical Royal Colleges, argued:

“There are nine regulators and I do not see why they cannot go down to two. In terms of CQC, we need to move to an inspection of a whole system of care and place-based health … We need a reduced number of professional regulators. For instance, if we are going to get physician associates up there and recognised, some of the big regulators need to decide who is going to do that. Inspections need to be separate but they need to work together better.”118

144.Professor Cathy Warwick, Chief Executive of the Royal College of Midwives, told us that:

“I think I would say we need far less constraints around the workforce; we need to enable our workforce to work in far more innovative, enterprising sorts of ways. At the moment the regulatory and government structures make that incredibly difficult … We need a framework which is much looser and allows grass-roots innovation … “119

145.The point was echoed by Sir Cyril Chantler, the eminent paediatrician:

“I am not against regulation; regulation is important. There are just too many of them all trying to do the same thing. There are too many agencies as part of the central system of the National Health Service now. I do not want them reorganised but a bit of rationalisation would be quite useful.”120

He went on to speculate about the structural cause:

“… I think it comes from the nature of the top-down organisation of a healthcare system funded through taxation, which is what Beveridge and Bevan put in place. It is the right model but with it comes a responsibility upwards which leads to downward control.”121

146.In April 2014 the Law Commission, Scottish Law Commission and Northern Ireland Law Commission published their report Regulation of Health Care Professionals: Regulation of Social Care Professionals in England.122 The report included a draft bill to reform the legal framework around the regulation of health care professionals. The draft bill envisaged a single legal framework for all the regulators of health and social care professionals. The existing governing legislation (such as the Medical Act 1983, the Dentists Act 1984 and the Nursing and Midwifery Order 2001) would be repealed, and replaced with a single Act of Parliament to provide the legal framework for all regulated professionals. The Government has yet to bring a bill forward, though a Private Members’ Bill has been introduced in the House of Lords encouraging them to do so. The Regulation of Health and Social Care Professions Etc. Bill [HL] was introduced by Lord Hunt of Kings Heath and received its first reading in the House of Lords on 26 May 2016, and received its second reading on 3 February 2017. The Bill, if passed, would require the Government to bring forward legislation giving effect to the recommendations of the Law Commission, Scottish Law Commission and Northern Ireland Law Commission in their report. We wholeheartedly support the objectives of the Bill.

Morale, pay and retention

147.Dr Mark Britnell, Partner and Chairman at the Global Health Practice at KPMG, told us that one of the most important things for a sustainable health system was staff morale and he exhorted us to “love your workforce and motivate and direct it properly.”123 Baroness Cavendish of Little Venice spoke at some length about the morale problems in the NHS:

“… we need to reignite enthusiasm, and there is a morale problem in the NHS. However, what I saw in No. 10 for the first time ever … was a bunch of really talented people, clinicians and chief executives, who for the first time seemed to be genuinely determined to change things … On the one hand, you have people who are extremely concerned—the financial situation is dire, people are in deficit, there is a concern that deficit will become normalised—and on the other hand there is a group of people who want to grab the opportunity to change. The gap is that we have not provided a sufficiently clear template to them for what to do, and there are some very bright people out there who are very busy, and they do not want to have to reinvent the entire wheel again in their patch.”124

148.We were particularly concerned to hear from Sir Cyril Chantler that there was a climate of fear amongst the workforce which was being created by excessive levels of top-down accountability and over-regulation.125

149.We received evidence on the lengthy period of pay restraint experienced by health and care staff and the consequential impact of this pay restraint on morale. This was a particular problem for those who were often at the lower end of the pay scale such as nurses, other healthcare workers and social care workers. It was clearly a relevant factor in the low levels of morale and significant staff retention problems we heard about. Sam Higginson, Director of Strategic Finance at NHS England, told us that the working efficiency calculations within the Department of Health assumed that pay restraint would continue up to 2019/20. Michael Macdonnell, Director of Strategy at NHS England conceded that in his opinion, 10 years of prolonged pay restraint were bound to have long-term effects on workforce morale.126

150.Professor Alan Manning, Member of the Migration Advisory Committee, told us that:

“If one is focusing on long-term sustainability and the workforce side, I worry that pay gets determined as a residual. There is a bit of temptation to think, ‘This is the health service we would like to provide, this is the amount of money we have been given and, therefore, this is what we can afford to pay our workforce’. In the long run, you have to pay your workforce what makes these professions attractive to recruit and retain them, given the other choices that people have, and you cannot control how much those other choices pay.”127

151.There were concerns expressed about the capacity of the NHS to retain domestically-trained staff because of low pay and morale and the competitiveness of the international market for scarce clinical skills. The evidence suggested this was a particular issue in nursing, where the proportion of nurses leaving services increased from 6.8% in 2010–11 to 9.2% in 2014–15.128 This link between pay and retention was developed by Dr Jennifer Dixon, Chief Executive of the Health Foundation:

“Our work has shown that there are a lot of things that could be done locally to improve retention—not just for nursing staff but for others. HR management is a pretty underpowered profession. We just do not devote enough thinking in national or local policy to the wellbeing and motivation of staff, even though they are our biggest asset. Overall, if you look at the figures for staff joining and leaving the NHS, in some years the percentage joining and leaving is more or less the same, so you have a big leaky bucket.”129

152.ADASS told us that retention in the adult social care workforce was also a problem: “Those who feel they are underpaid for difficult and often emotionally draining work are liable to seek alternative employment.”130

153.There is an indisputable link between a prolonged period of pay restraint, over-burdensome regulation and unnecessary bureaucracy on the one hand and low levels of morale and workforce retention on the other. We recognise the necessity of public sector pay restraint when public expenditure is under considerable pressure. However, by the end of this Parliament, pay will have been constrained for almost a decade.

154.We recommend that the Government commissions a formal independent review with the involvement of the Department of Health, the pay review bodies and health and care employers to review pay policy with a particular regard to its impact on the morale and retention of health and care staff.

155.The current regulatory landscape is not fit for purpose. In the short term, we urge the Government to bring forward legislation in this Parliament to modernise the system of regulation of health and social care professionals and place them under a single legal framework as envisaged by the 2014 draft Law Commission Bill. The Government should also introduce legislation to modernise the system regulators to take account of our recommendation that NHS England and NHS Improvement be merged and to reflect the clear move towards place-based care.

72 NHS, ‘The NHS in England: About the National Health Service (NHS)’: [accessed 28 March 2017]

73 NHS Improvement, Submission to the NHS Pay Review Body and the Review on Doctors’ and Dentists’ Remuneration (September 2016): [accessed 28 March 2017]

74 Written evidence from The Association of Directors of Adult Social Services (ADASS) (NHS0072)

75 NHS England, Five Year Forward View (October 2014), pp 29–30: [accessed 28 March 2017]

76 The Shape of Training Review, also known as ‘The Greenaway Report’, looked at potential reforms to the structure of postgraduate medical education and training across the UK. Shape of Training, Shape of Training: Securing the future of excellent patient care (October 2013): [accessed 28 March 2017]

77 The Shape of Caring Review, also known as ‘Raising the Bar’, looked at how to ensure that throughout their careers nurses and care assistants receive consistent high quality education and training to support high quality care. Health Education England, Raising the Bar: Shape of Caring: A Review of the Future Education and Training of Registered Nurses and Care Assistants (March 2015): [accessed 28 March 2017]

78 This report highlighted interim findings from Horizon 2035, a piece of work commissioned by the Department of Health to consider how a series of challenges and opportunities may combine in the future and impact the health, public health and social care workforce. Centre for Workforce Intelligence, Horizon 2035 Future demand for skills: initial results (August 2015): [accessed 28 March 2017]

79 Q 4 (Gavin Larner)

80 Q 7 (Gavin Larner)

81 Q 26 (Dr Jennifer Dixon)

82 Health Education England, ‘About us’: [accessed 28 March 2017]

83 Q 130 (Professor Ian Cumming)

84 The Conservative Party, The Conservative Party Manifesto (2015), p 38: [accessed 28 March 2017]

85 Q 287 (Dr Sarah Wollaston MP)

86 Q 152 (Candace Imison)

87 Written evidence from the Royal College of Physicians (NHS0065)

88 Written evidence from Mind (NHS0179)

89 Written evidence from the Royal College of Midwives (NHS0067)

90 Written evidence from Care England (NHS0089)

91 Written evidence from the Recruitment and Employment Confederation (NHS0052) and Skills for Care, The state of the adult social care sector and workforce in England (March 2015):,-workforce-intelligence-and-innovation/NMDS-SC/State-of-2014-ENGLAND-WEB-FINAL.pdf [accessed 28 March 2017]

92 Q 132 (Danny Mortimer), Q 160 (Dr Mark Porter), Q 171 (Dame Julie Moore) and Q 288 (Dr Sarah Wollaston MP)

93 Q 132 (Professor Ian Cumming)

94 Written evidence from Independent Age (NHS0053)

95 Q 313 (Jeremy Hunt MP)

96 Q 303 (Jeremy Hunt MP)

97 Written Answer, HL 47397, Session 2016–17

98 The King’s Fund, the Nuffield Trust and the Health Foundation, The Spending Review: what does it mean for health and social care? (December 2015): [accessed 28 March 2017] and also see Health Service Journal ‘Exclusive: HEE budget freeze will have ‘consequences’ for NHS’: [accessed 28 March 2017]

99 Q 130 (Professor Wendy Reid)

100 Written evidence from Dell EMC (NHS0070)

101 Written evidence from The Association of Anaesthetists of Great Britain and Ireland (AAGBI) Group of Anaesthetists in Training (GAT) (NHS0115), The Faculty of Public Health (NHS0154), The Royal College of Emergency Medicine (NHS0029), The Royal College of Midwives (NHS0067) and The Royal College of Paediatrics and Child Health (NHS0133)

102 Written evidence from NHS Improvement (NHS0107)

103 Q 130 (Professor Ian Cumming and Professor Wendy Reid)

104 Q 131 (Professor Ian Cumming)

105 Q 150 (Candace Imison)

106 Q 24 (Richard Murray)

107 Q 206 (Ian Eardley)

108 Q 212 (Professor Cathy Warwick)

109 Q 223 (Natalie Beswetherick)

110 Q 11 (Gavin Larner)

111 Q 238 (Professor Sir John Bell)

112 The two system regulators are NHS Improvement and the Care Quality Commission (CQC). The nine health and care regulators register health and care professionals working in occupations that statute has said must be regulated. They are the General Chiropractic Council (GCC), the General Dental Council (GDC), the General Medical Council (GMC), the General Optical Council (GOC), the General Osteopathic Council (GOsC), the Health and Care Professions Council (HCPC), the Nursing and Midwifery Council (NMC), the General Pharmaceutical Council (GPhC) and the Pharmaceutical Society of Northern Ireland (PSNI).

113 Q 262 (Professor Sir Mike Richards)

114 Q 189 (Dr Clare Gerada)

115 Q 189 (Professor Maureen Baker)

116 Q 270 (Baroness Cavendish of Little Venice)

117 Letter from the Chief Executive of the CQC, Sir David Behan, to the Chairman, 15 February 2017: [accessed 28 March 2017]

118 Q 202 (Professor Dame Sue Bailey)

119 215 (Professor Cathy Warwick)

120 Q 270 (Sir Cyril Chantler)

121 Q 267 (Sir Cyril Chantler)

122 Law Commissions, Regulation of Health Care Professionals: Regulation of Social Care Professionals in England, Cm 8839 (April 2014): [accessed 28 March 2017]

123 Q 318 (Dr Mark Britnell)

124 Q 267 (Baroness Cavendish of Little Venice)

125 266 (Sir Cyril Chantler)

126 Q 32 (Sam Higginson and Michael Macdonnell)

127 Q 134 (Professor Alan Manning)

128 Written evidence from UNISON (NHS0081)

129 Q 25 (Dr Jennifer Dixon)

130 Written evidence from The Association of Directors of Adult Social Services (ADASS) (NHS0072)

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