Written evidence submitted by The Institute for Public Policy Research (WBR0062)

Introduction

1. The Institute for Public Policy Research (IPPR) is a registered charity and the UK’s pre-eminent progressive think tank. IPPR engages with the public, with opinion formers, policymakers and politicians of all parties and none. We are dedicated to creating a more prosperous, more sustainable and fairer country.

2. The Better Health and Care Programme is IPPR’s programme focusing on the future health and social care in the UK. Independently chaired by Lord Ara Darzi, it puts forward evidence and policy to support the creation of a fairer, more sustainable and more universal health and care system.

3. This submission highlights relevant research from the Better Health and Care Programme – where resilience is a key area of expertise.

How resilient was the NHS and social care workforce under pre-Covid-19 operating conditions, and how might that resilience be strengthened in the future?

4. The NHS and social care workforce had a severe resilience deficit under pre-Covid-19 operating conditions. A key problem was a lack of workforce numbers – particularly in relation to a growing and ageing population.

5. In July 2020, IPPR published a new study Resilient Health and Care: Learning the Lessons of Covid-19[1]. This showed that the UK had some of the lowest numbers of doctors and nurses – relative to population size – of any advanced economy. To reach the OECD average, the country would require an additional 20,584 doctors and 28,552 nurses. To reach the 75th per centile - a more realistic level for a country with the UK’s health expenditure - would require an extra 70,000 more doctors and 220,000 more nurses[2].

6. This research also showed that the UK has a small and declining long-term care workforce. To reach the 75th percentile of the OECD, we would need 7.3 long-term care workers for every 100 people aged over 65. Currently, we have just 3.3[3].

7. A key reason for a growing shortage of staff is worsening work conditions, often linked to austerity. On the one hand, workload and stress has increased. In 2019, around half a million NHS workers reported ill health caused by stress – up 100,000 since 2015. On the other hand, reward has decreased[4]. IPPR research in July 2020 estimated that Band 5 nurse pay is still 10 per cent behind 2010 levels[5], even accounting for the 2018 pay deal[6]. Moreover, 2018 research on the social care workforce showed that half of all care workers were being paid below the real living wage[7].

8. In turn, declining numbers mean more work and stress for the remaining workforce. This creates a vicious cycle – where stress, leads to vacancies, which leads to more work and more stress. This is only made worse by demand spikes or shocks – whether a global pandemic, or a bad case of winter flu. It is important policy aims to break this cycle and create more sustainable working conditions.

What has the impact of the Covid-19 pandemic been on resilience, levels of workforce stress and burnout across the NHS and social care sectors?

9. IPPR analysis suggests that Covid-19 has had a potentially catastrophic impact on workforce stress and burnout during 2020. Polling of the healthcare workforce undertaken at the peak of the Covid-19 outbreak in April showed that
    
1. One in two workers felt their mental health had declined since the start of the outbreak
2. Almost three and four were unsatisfied with efforts to protect their physical health
3. Over a third of workers aged 35 to 44 said they’d experienced barriers around childcare
4. Those working for private companies – for example, through outsourcing arrangements – often felt insecure about their job (one in three, compared to just 5 per cent in the NHS)[8]

10. Consequently, many may now be more likely to leave the sector than they were before. Our polling from over 1 in 5 felt Covid-19 had made them more likely to leave healthcare work[9]. In the NHS, this would be the equivalent of around 300,000 workers – at a time of severe healthcare backlog and staffing shortage.

11. This would compound existing vacancies and turnover rates in the sector. These are highest in adult social care. Skills for Care estimates that social care already had 122,000 vacancies and a turnover rate of over 30 per cent before Covid-19[10].

What are the impacts of workforce burnout on service delivery, stress, patients and service users across the NHS and social care sectors?

12. Where burnout and stress lead to staff shortages, there is usually a significant detriment on access to services. For example, General Practice is one of the most overworked parts of the health system. Correspondingly, GP numbers have stagnated over the last decade[11]. We now have the lowest number of GPs, relative to our population size, since 2003[12].

13. In turn, there have been significant access problems. Our February 2020 report The Neighbourhood NHS showed that 36 per cent of people in England were waiting more than a week for an appointment – and that 3 per cent, equivalent to 1.7 million people, were not able to book one at all[13]. This leads to late diagnosis, worse outcomes and increased strain on Accident and Emergency departments.

14. Where stress and burn out do not leave staff to leave - but see them working at the top of their capacity, rather than the top of their game - there can be significant patient safety implications. The NHS still has patient safety problems. From October 2018 to September 2019, there were 4,000 safety incident reports resulting in death, and nearly 60,000 moderate-to-severe incidents[14]. Evidence is clear that staffing gaps, poor staff morale and toxic cultures underpin excess patient safety incidents[15].

Will the measures announced in the People Plan be enough to increase resilience, improve working life and productivity, and reduce the risk of workforce burnout across the NHS – both now, and in the future?

15. There is a need for more ambitious policy on recovery from Covid-19. The ambition should be not just to get back to the way things were in 2019, but also to deliver a more sustainable settlement for the workforce. This should cover key wellbeing deficits across the health and care workforce: pay, mental health, childcare and housing.

16. Specifically, relevant IPPR recommendations include:

1. Better mental health support: Including guaranteed opportunities for clinical supervision, either individually or in group fora; personalised health care plans for all who need them; and extension of specialist NHS support available to doctors, to all NHS and social care workers.
2. Minimum pay standards: No health or care worker should earn below the minimum wage. All health and care workers should receive a 10 per cent ‘Covid-19 bonus’, recognising both the real terms pay cut received during the austerity public sector pay freeze, and their remarkable work during the outbreak.
3. Childcare support: Free uplift to NHS and social care worker childcare provision, as implemented in Wales. Work with NHS and social care providers to extend crèches programmes to all.
4. Housing support: Support to avoid rental arrears and evictions during the pandemic. In the long-term, the government should consider ways to ensure key workers have priority access to affordable housing around the area they live/work[16].

17. The People Plan also failed to sufficient address key long-term trends, which workforce planning will need to pre-empt (or harness). Amongst these are:

5. Automation: Automation could release ‘time to care’ worth almost £13 billion. But this relies on careful planning, to ensure a) inequalities do not emerge b) workers are able to use technology effective and c) automation is considered properly in workforce composition. This has not been adequately considered[17].
6. Changing needs: The ageing population is changing needs rapidly. Multiple conditions are a new health frontier, presenting unique challenges. Yet, we have an ever more specialised workforce.
7. Global shortage: We have often relied on international recruitment at times of workforce shortage. Yet, there is a growing global shortage of health and care workers. This has not been pre-empted[18].
8. Scientific discovery: The pace of scientific discovery and knowledge accrual is rapid. Yet, training, role profiles and medical schools are not keeping up. If this continues, we will fail to harness exciting innovations, and maintain our place at the frontier of health and care
9. Health insecurity: Covid-19 was not a once in a lifetime event. Rather, health insecurity is the new normal, and one we need to react to. That means measures are needed to pre-empt and manage the impact of demand spikes on workers[19].

18. A funded and long-term strategy should be a priority. It should look beyond the next few years, and explore how we can build a future focused workforce fit for the coming decades.

What further measures will be required to tackle and mitigate the causes of workforce stress and burnout, and what should be put in place to achieve parity for the social care workforce?

19. Recruitment is key, to ensure that workload can be managed in a sustainable way. This time could be filled by rest and recovery, but also by valuable activities like development, training and research. IPPR have shown what this would look like in primary care, with a proposal for a new type of salaried GP – based on portfolio models. They would have less work, sessions dedicated for non-clinical activities, and more leadership responsibility[20].

20. Learning from other crises may be useful. In the face of fiscal insecurity, the government introduced ‘fiscal rules’ in the 1990s. These committed the government to a set, long-term approach. In health and care, building long-term thinking into policy in a similar way may be useful – to ensure decisions are not just based on immediate value, but on efficiency and quality over a sustained period. IPPR has recently recommended adoption of ‘health and care resilience rules’ to this end[21].

21. On workforce, we specifically recommend a resilience rule as follows. The government should expand and fund the People Plan process, and ensure it covers social care. Beside that, government should commit to recruiting at least an additional 250,000 people into the NHS and 400,000 people into social care by 2030. To support that, legislation should be introduced that guarantees health and care workers an immigration fast track until that target is met – defined as skilled worker status and exemption from Visa fees and the NHS surcharge. This recruitment drive should be supported by a £3.5 billion training budget over this parliament[22].

22. There are immediate steps the department could take to create parity between health and social care. Firstly, they could provide a fairer pay settlement to social care. IPPR recommend benchmarking social care worker pay against Band 3 NHS workers (e.g. emergency care assistants) - with private providers unable to bid for public contracts unless they meet this stipulation[23]. Secondly, they could provide more equal training budgets for health and social care workers.

23. Elsewhere, we recommend strengthening social care workforce rights through:

1. Greater efforts to support unionisation of workers
2. Reform to create a functional social care system, for example through free personal social care and a new care regulator (OfCare)
3. Efforts to professionalise the care sector – for example, through the Care Certificate
4. Efforts to create more career development opportunities in the social care sector[24]

These are elements of work life available in the NHS. Providing them in adult social care would help create work parity.

Chris Thomas, Senior Research Fellow, Institute for Public Policy Research

Sept 2020