Third Report - Workforce: recruitment, training and retention in health and social care

We welcome the previous Secretary of State’s determination to meet his duties under section 41 of the Health and Care Act. To meet these duties, the new Secretary of State must lay before Parliament objective, transparent and independently audited reports on workforce projections for health, public health, and social care that cover the next five, ten, and twenty years. The reports should state current staffing levels, future staff projections, and an assessment of whether sufficient numbers are being trained in each profession, specialty, and sub-specialty. Demand should be modelled on demographic changes in the patient population and amongst staff, and should consider the role of technology, and changes to costs and treatments.

Without full and frank transparency on projected workforce gaps, the public and NHS staff can have little confidence that the Government has grasped the depth of the workforce crisis, and little confidence in Framework 15 or the NHS workforce strategy. The Government must authorise arm’s length bodies to publish data on workforce gaps to restore public confidence, to increase transparency, and to facilitate parliamentary scrutiny of the Government’s plans. It must publish the full report of the NHS workforce strategy complete with gap analysis and workforce projections for the next five, 10, and 15 years for each profession by the end of 2022. (Paragraph 34) Recruitment in Health

The Government’s current target of recruiting 50,000 NHS nurses is not having any meaningful impact on the true scale of nursing shortages. The Government must introduce a new bursary scheme comprising full coverage of tuition fees, a non-means- tested grant of at least £1,000, and a means-tested bursary. In addition, nursing and midwifery students who take up this bursary should be guaranteed, where possible, at least 3 years of work in the NHS Trust in which they trained, to eliminate the need for them to seek agency work after graduation.

It will not be possible to re-recruit those who have voluntarily surrendered their medical licences without addressing the factors which caused them to do so. For many retirees, this means addressing pensions and the development of “retire and return” policies, for others, this means addressing poor workplace cultures. We will return to these issues later in the report.

Formal re-entry programmes, akin to those which already exist for primary care, should be developed by the NHS, Health Education England, the General Medical Council, and other relevant bodies for secondary care doctors who wish to return to work after a long break.

Given the success of training to task during the pandemic, the Government must consult with relevant bodies to explore further opportunities to mobilise this willing group of volunteers. They must also consider whether further changes to the law are necessary in order to allow more volunteers to work on a temporary basis on specific tasks in the NHS. (Paragraph 47) 58 Workforce: recruitment, training and retention in health and social care

Maternity services in England and Wales are under unsustainable pressure. We welcome the commitments that the Government has made in response to the Ockenden report, whilst recognising that these changes will come too late for some mothers and babies. The Government must intervene with immediate action on recruitment and retention to relive pressure from the system and ensure positive birthing experiences for everyone, regardless of their racial or socioeconomic background.

In July 2021, we recommended that NHS England needed an additional 1,932 midwives and 496 obstetricians to operate at a level that Birthrate Plus considered safe. Rather than adding to their headcount, NHS England has lost 552 midwives between March 2021 and March 2022. This indicates a clear problem with midwifery retention. Despite requests to NHS England and the Secretary of State for a date by which these safe staffing levels would be reached, no date has been set. This failure to respond demonstrates a lack of responsibility taking and is absolutely unacceptable. Without a clear workforce plan for midwifery staffing, and the wider maternity workforce in general, the public can have no confidence that the Government or the NHS has grasped the seriousness or scale of the situation in which it finds itself. We urge the Government and the NHS to publish a plan for recruiting the recommended additional midwives and obstetricians needed to create safe staffing levels in maternity services.

There is an urgent need for a robust and funded maternity-wide workforce plan, which must be delivered without further delay. The Government must commit to funding, recruiting, and retaining the workforce at the level set out by the forthcoming report of the Royal College of Obstetricians and Gynaecologists. Once this report has been published, the Government must set out a plan within six months for how it intends to recruit the number of people to deliver the level of staffing that the Royal College deems necessary to deliver safe and compassionate care to mothers and babies.

The Government has accepted the recommendation, first made by this committee and then by the Ockenden report, that maternity services should be funded by an additional £200–350 million per annum. The Government must lay before Parliament, within six months, a plan for this spending increase, detailing exactly how much additional investment will be made, where the investment will be made, and plans for the next one, five, and 10 years of spending.

Improving diversity in the recruitment of midwives will improve the standard of care that black, Asian, mixed-race, and minority ethnic women receive throughout pregnancy, birth, and the post-natal period. Health Education England should set forth a recruitment plan with clear targets to increase the ethnic diversity of people going into midwifery.

NHS England must publish interim figures reporting on how close it is to achieving its target of 75% of women from black and minority communities and a similar percentage of women from the most deprived groups receiving continuity of care from their midwife throughout pregnancy, labour, and the postnatal period by 2024. (Paragraph 61) Workforce: recruitment, training and retention in health and social care 59

Administrative barriers are often placed in the way of talented international medical graduates who wish to work in the NHS. In particular, it can be difficult for them to join the specialist register. To streamline this process, and boost recruitment into the NHS, the General Medical Council should introduce a “green list” of countries whose doctors are given an automatic right to practise in the UK following the minimum necessary checks. In the short-term, the General Medical Council should undertake a review of the Certificate of Eligibility for Specialist Registration processes to ensure that the demands being made on international medical graduates are fair and proportionate.

International recruitment from the developing world must be done in an ethical way, and the Academy of Medical Royal Colleges’ Medical Training Initiative, which recruits international medical graduates to work in the NHS for a fixed-term period with a specific remit of improving the quality of healthcare in developing countries is the gold standard of this practice. The Government should invest in and expand the Medical Training Initiative.

Many health and social care workers have caring responsibilities, including for adult relatives. The Government must commit to revising the amount of proof that must be provided to bring an adult dependant into the UK through the Sole Responsibility and Adult Dependant visa routes to ensure that it is not acting as a deterrent to the recruitment and retention of health and social care staff.

The practice of requiring medical staff entering the country on Tier 5 visas to pay and reclaim the NHS surcharge should be scrapped.

All international medical graduate GP trainees should be offered leave to remain in the UK upon successful completion of GP speciality training. This would encourage them to live and work in the UK, protecting the NHS’s investment and boosting the GP headcount.

There should be more support both for newly qualified international GPs and their would-be employers. There should be a default visa extension for six months after the international medical graduate’s expected GP training completion date, to give them time to find an appropriate employer. The Home Office and UK Visas and Immigration should work with the NHS to support GP practices to become sponsors for international medical graduates. Further support should be provided to support the integration and retention of international GPs in the UK, including making it easier for them to bring immediate family members to the UK. (Paragraph 75) Retention in Health

The NHS must ensure that all staff have access to adequate facilities. At the minimum, all staff should have access to 24/7 hot food and drinks, free parking, and places to rest, store their belongings, shower and change, and take breaks with colleagues. The NHS should conduct a welfare provision assessment to consider how to move towards this. (Paragraph 78) 60 Workforce: recruitment, training and retention in health and social care

The Government should review the provision of affordable and flexible childcare for people working in the health and social care sector, and assess whether it is possible to improve it.

Managed well, the trend towards less-than-full-time and flexible working will be a powerful force in making the NHS a more attractive employer. However, in order to maintain standards of care for patients and offer truly flexible working to staff, the NHS will have to increase its overall staff headcount. It is impossible to say by how much or where this increase will have to take place because the Government’s workforce modelling has been wholly insufficient and has failed to consider the impact that less-than-full-time working is having on headcount in different specialties. What is needed, most of all, is a long-term workforce plan for the NHS, which takes the trend for less-than-full-time working into account when predicting the number of people that the NHS needs to train in each specialty in five, 10, and 20 years’ time.

Whilst we welcome changes made to the NHS contract that give every NHS worker a “day one” right to request flexible working, it is clear that this has been insufficient to make flexible working a daily reality in the NHS. No NHS employee should be choosing to locum or work for an agency to regain control over their working life. The NHS must commit to a review of flexible working arrangements in all Trusts, with a view to ensuring that within 12 months all NHS staff have similar flexibilities in their working arrangements to those enjoyed by locum or agency staff. Reduced or flexible hours must be made available to everyone, but especially those with caring responsibilities or those nearing retirement, and investment should be made in technologies which make home-working or remote consultation possible.

It is unacceptable that some NHS nurses are struggling to feed their families, pay their rent, and travel to work. To reflect the crucial work that they do to keep the NHS running, and to improve recruitment and retention, the Government must give all NHS staff employed under Agenda for Change a pay award that takes adequate account of the cost-of-living crisis.

The NHS must review the job descriptions used for nursing and midwifery roles under Agenda for Change to ensure that nurses and midwives are being paid fairly for the safety critical roles that they deliver.

It is a national scandal that senior medical staff are being forced to reduce their working contribution to the NHS or to leave it entirely because of NHS pension arrangements. Clearly, the Government’s changes to tax regulations have not gone far enough to remedy this crisis. With mounting waiting lists and ever-increasing demands, the NHS cannot afford to lose staff who are willing and able to work, and urgent action is needed to reform NHS pensions and prevent the haemorrhage of senior staff. The Government must act swiftly to reform the NHS pension scheme to prevent senior staff from reducing their hours and retiring early from the NHS.

The temporary suspension of regulations governing the administration of NHS pensions, made under the Coronavirus Act 2020, helped to ameliorate this issue during the pandemic. The Government should consider ways to achieve the same outcome now the pandemic is behind us. (Paragraph 104) Workforce: recruitment, training and retention in health and social care 61

NHSE should develop a national NHS “retire and return” policy to replace ad hoc local schemes. In the short term, the Government should instruct NHS England to require NHS Trusts to follow pension recycling guidance it has already issued to help deal with the short-term impact of the pension problem.

The current UDA-contract system is not fit for purpose, and urgent reform is needed to boost recruitment and retention in NHS dental services. We will return to this issue in a forthcoming inquiry into dental services.

There is an opportunity to better utilise the pharmacy workforce, and in doing so, to optimise workloads across primary care, reduce pressure on general practice and hospitals, and support integrated care systems. This optimisation will not be possible without an integrated and funded workforce plan for pharmacy which must be developed and laid before Parliament within 12 months. The plan must ensure that all pharmacists have adequate access to supervision, training, and protected learning time, along with clear structures for professional career development into advanced- and consultant-level practice. The workforce plan for pharmacy must consider that by 2027 all newly qualified pharmacists will be independent prescribers and ensure that these graduates are given protected learning time, adequate supervision, and career development opportunities. (Paragraph 111) Training in Health

In the absence of an independent mechanism to assess the increase necessary, we agree with the recommendation of the Medical Schools Council and the Academy of Medical Royal Colleges that the number of medical school places in the UK should be increased by 5,000 from c.9,500 per year to 14,500. This increase is a long-term solution to bolster the ranks of the NHS and increase overall headcount, but more immediate short-term actions, detailed elsewhere in this report, must also be taken to address the current crisis.

As part of the expansion of medical schools, the cap on the number of medical school places offered to international students should be lifted by allowing full registration at the end of the Primary Medical Qualification and asking international students to fund the cost of their foundation year placements.

Should the Government increase the number of medical school places, they must consider an appropriate increase in the size and resourcing of medical schools, including in their facilities and faculty, as well as increased numbers of clinical placements spread throughout the country, and more speciality training positions for the increased number of graduates produced.

The 2018 cohort of medical schools are proving a success story in terms of widening participation, and in producing cohorts of local doctors who are more likely to stay local to their training centre once they have graduated. The Government must commit to expanding the number of places available at the 2018 cohort of medical schools, starting in the academic year 2023–24. (Paragraph 127) 62 Workforce: recruitment, training and retention in health and social care

If the 2018 cohort are dependent on international recruitment, the benefit of their placement in under-doctored areas is likely to be eroded. The Government must ensure that the 2018 cohort, and all medical schools, are appropriately funded to train UK students.

The Department of Health and Social Care must commit to reviewing the process by which student clinical placement tariffs are set to establish why there is such a large difference between medical and non-medical clinical student tariffs. This review should be completed with the goal of understanding how tariff money is spent and establishing a transparent evidence base on which to inform decisions about how tariff rates will be set and how tariff money will be spent in the future.

We believe that the General Medical Council’s emphasis on acquiring competency in postgraduate training, rather than focusing on “time-served” is the right way to go. The Government must commission an independent review of all postgraduate training to consider whether it is possible to i) reduce the time it takes to obtain a postgraduate qualification, whilst maintaining rigorous patient safety and professional standards; ii) ensure that those who train less-than-full time are not penalised for doing so; and iii) and to provide an independent assessment of how many training places are needed for each specialty. Once this review is completed, the Government must implement its findings, including committing to funding the number of training places required.

NHS England must ensure that temporary, bank, and agency staff are given full access to NHS training to allow them to level up their skills, to ensure that they are able to sign up for additional shifts. (Paragraph 141) Working culture, including the experience of ethnic minority health and care workers

We were horrified to hear clear evidence of racism within the NHS, with some staff subjected to racist bullying, harassment, and abuse from colleagues and patients. This behaviour is unacceptable anywhere, and we condemn it expressly here. Tackling racism is a recruitment and retention issue, and the NHS and Government must take it extremely seriously.

There should be greater accountability from NHS senior and middle management for the reduction of incidents of racist discrimination amongst staff. This should include explicit equality, diversity, and inclusion responsibilities in senior leadership job role descriptions, against which the performance of senior leaders is reviewed, and to which their pay and promotion is linked.

The NHS is not the only public sector organisation which finds itself facing the challenge of tackling racism. Given that addressing inequalities is a cross-government priority, the Government must commission a What Works Centre to research issues of discrimination in public sector workforces, to collate an evidence base around existing initiatives, and to co-ordinate learning across the public sector.

We welcome the roll-out of a pilot Social Care Workplace Racial Equality Standard to some local authorities and encourage the Government to extend the Social Care Workforce: recruitment, training and retention in health and social care 63 Workplace Racial Equality Standard across all local authorities. However, we also recognise that the Social Care Workplace Racial Equality Standard will not capture the experience of the majority of social care workers, who are employed in the independent sector. The Government must fund Skills for Care to pilot the Social Care Workplace Racial Equality Standard in the independent sector within 12 months.

The NHS has shown through the pilot scheme in the East of England that setting up independent review panels to review anonymised case information before cases are formally referred to the General Medical Council results in parity of referral between white and ethnic minority doctors. This practice must be rolled out to all NHS Trusts as a matter of urgency to ensure that the referral process is operating fairly and equally for everyone.

We welcome the General Medical Council’s new targets to eliminate disproportionate complaints from employers about ethnic minority doctors (by 2026) and eradicate disadvantage and discrimination in medical education and training (by 2031). The Nursing and Midwifery Council must introduce parallel targets to eliminate disproportionate complaints from employers about ethnic minority nurses and midwives and to eradicate disadvantage and discrimination in nursing and midwifery education and training by the same dates.

Talented women are missing out on the opportunity to become surgeons because of a lack of support and role models. The NHS should develop a strategy to attract and retain more women into surgery.

It is unacceptable that the gender pay gap persists in medicine. The Government should make a report on progress made against recommendations on how to close this gap made in ‘Mend the Gap: The Independent Review into Gender Pay Gaps in Medicine in England”.

NHS England should develop and implement a national menopause strategy focused on the retention of senior staff who may be reducing their hours, leaving management or supervisory roles, or retiring earlier than intended, because of a lack of support around menopause.

The NHS should look to improve its complaints procedure to ensure that doctors are supported throughout any investigation or inquiry, including to the General Medical Council, and are protected in particular from spurious, vexatious, or discriminatory complaints.

The Government should consider whether reforms can be made to the Medical Act 1983 to ensure that General Medical Council regulatory processes can be simplified to reassure both the public and clinicians, without the loss of accountability.

The NHS must commit to the creation of positive working cultures and inclusive work environments. They should do this through creating and enforcing zero tolerance policies for harassment, discrimination, and bullying towards all staff, with targeted policies for staff who may be particularly vulnerable to these behaviours, and online behaviours. (Paragraph 173) 64 Workforce: recruitment, training and retention in health and social care

In this context, it is important that the Government looks at ways of improving short term efficiency to promote positive mental health and headspace for all frontline workers. It could do this through looking at ways to reduce bureaucracy—perhaps through the use of technology—and reducing the time that frontline workers spend on administrative tasks. This could be achieved through reinstating administrative support staff and by investing in adequate ICT infrastructure. The cumulative effect of these measures would be to help give clinicians and frontline workers the capacity for headspace. (Paragraph 176) Retention in Social Care

Witnesses to this inquiry left us in no doubt that pay is a crucial factor in recruitment and retention in social care. Social care providers are consistently being outbid by the retail and hospitality sectors. However, whilst pay increases are sorely needed, merely raising wages is not enough. A long-term, sustainable strategy is needed which includes the prospect of pay progression, professional development, training, and career pathways.

NHS England employs 104,000 people in adult social care jobs. NHS England must undertake a review of pay in their social care jobs. In the review, NHS health and social care roles must be compared based on the skills, competencies, and levels of responsibility shown in various roles in each sector to ensure that social care roles are being paid fairly.

We reiterate the recommendation made in our ‘Social care: funding and workforce’ report that annual funding for social care should be increased by £7 billion by 2023–24. This will account for demographic changes, uplift staff pay in line with National Minimum Wage and protect people who face catastrophic social care costs.

We welcome the Fair Cost of Care exercises as an opportunity to address the underfunding of the social care sector. However, these exercises must not be used as an excuse to reinforce the low pay which is endemic in the sector. The Government must ensure that the cost of care is calculated on the basis of paying care workers the same rate as equivalent NHS roles: Band 3 on Agenda for Change. (Paragraph 186) Continuity of care

We have heard evidence that staff shortages are having an impact on the ability of social care staff to provide good-quality care to the people they support. Lara Bywater told us that in the 20 years she has been running her organisation, she has “never seen a staff shortage impact like this”. She emphasised that:

We welcome the Fair Cost of Care exercises as an opportunity to address the underfunding of the social care sector. However, these exercises must not be used as an excuse to reinforce the low pay which is endemic in the sector. The Government must ensure that the cost of care is calculated on the basis of paying care workers the same rate as equivalent NHS roles: Band 3 on Agenda for Change. (Paragraph 186) Workforce: recruitment, training and retention in health and social care 65

The work that social carers do is essential to the lives of those who are cared for, and to their families. It is vital that they are treated by the Government and by wider society with the same respect as their NHS colleagues. It is not until parity of esteem between the NHS and social care is achieved that recruitment and retention in the social care sector will improve.

The value of continuity of care in social care settings, particularly for people who rely on non-verbal communication, is undeniable. It is essential that the Government acts swiftly to implement the findings of this report to improve retention in the sector.

Better training and career development pathways in social care will be an essential part of driving recruitment and retention in the sector. The Government must commit to restoring social care staff free access to the same NHS training as community health colleagues by July 2023.

It is clear that some care home managers lack the training and support they need to stay in post. We welcome the Government’s commitment to fund Level 5 diplomas for those who need them, and we urge the Government to publish a fully costed plan for doing so by the end of the year.

By 2023, the Government must introduce a new, mandatory Care Certificate which is i) subject to a formal assessment process, ii) externally offered and accredited, iii) offered at no cost to providers, and iv) portable between social care providers and between social care and the NHS.

The practice of “by-the-minute” commissioning is having a devastating impact on the continuity of care offered to service users and the terms and conditions under which workers must provide care. The reality is that some care is commissioned in this way because social care is chronically underfunded by central Government. It is within the Government’s gift to remedy this situation by providing adequate funding to the social care sector.

The Government must commit to providing sufficient funding for the social care sector so that Local Authorities and private providers are able to end the practice of “by- the-minute” commissioning of homecare. Local Authorities and private providers in turn must commit to paying workers in advance to provide care that is both relational and task-based and is focused on achieving outcomes. This will improve the quality and continuity of care offered to service users as well as terms and conditions for care workers.

It is completely unacceptable that the practice of not paying for travel time means that some domiciliary care workers are effectively working for less than the minimum or living wage. The Department for Business, Energy, and Industrial Strategy, with the support of HMRC must re-examine sector-specific guidance to address complexities in national minimum wage and national living wage guidance for the care sector, and reissue new, clarified guidance to employers and employees. The HMRC National Minimum Wage / National Living Wage enforcement body must be proactive in ensuring that all domiciliary care workers are receiving at least the minimum wage or living wage for all the time they spend working, including time spent travelling to appointments. (Paragraph 212) 66 Workforce: recruitment, training and retention in health and social care

New regulations should be introduced by 2023 in which care workers initially employed on zero-hours contracts must be offered a choice of contract after three months of employment. The new regulations should state that domiciliary care workers must be paid for their time spent travelling between appointments, and that time allocated for travel and care must be clearly set out in the contracts of domiciliary care workers. (Paragraph 213) Recruitment in Social Care

Wider market forces, including the rising cost of living, a lack of affordable housing, and a lack of public transport in remote locations are having an impact on the recruitment and retention of health and social care workers. These issues manifest differently across the country, and it is clear that without action to address these wider issues, the NHS and social care sectors will continue to struggle to recruit and retain staff.

Social care workers should be designated as key workers on the same basis as public sector employees so they can access affordable rented housing from local authorities and registered providers.

Local providers are best suited to understand the recruitment challenges in their local areas. The Government must pass recruitment and retention funds directly to providers to be invested in local recruitment campaigns.

The Government should report on how many care workers have been issued with Health and Care Worker visas since the scheme was launched. The salary requirement for the visa should be decreased to the average salary for a social care worker. Care workers should be considered skilled and added to the shortage occupation list.

International recruitment is too expensive for some social care providers. The Government should consider helping by waiving the cost of sponsorship certificates and licenses, including the immigration skills charge, for care workers and their sponsors, for two years, and other similar measures.

The NHS must undertake a review of its recruitment processes to ensure that no international health and care staff are being subject to punitive repayment clauses in their contracts. Those who are subject to repayment clauses must be released from them, and future NHS contracts must not contain repayment clauses.

Labour Market Enforcement bodies must work closely with external partners in social care to find ways to disseminate information and raise awareness about employment rights and the enforcement powers of Labour Market Enforcement bodies among employers (including those receiving direct payments), workers, and Local Authorities.

Local Authorities must evaluate the risk of modern slavery in their adult social care supply chains and ensure that the risk of modern slavery is assessed as part of the due diligence processes at the commissioning and contracting stage and in performance monitoring. They should ensure that there is effective information sharing between Workforce: recruitment, training and retention in health and social care 67 Local Authorities staff, recruitment agencies, and care workers to reduce occupational risks such as non-enforcement of minimum and living wage, and threats of physical or sexual violence. (Paragraph 235) 68 Workforce: recruitment, training and retention in health and social care