Further supplementary written evidence submitted by NHS Providers (MSE0114)

Dear Jeremy

I am writing further to our public letter to the committee dated 4 February regarding the inquiry into the safety of maternity services in England and your request for a detailed breakdown of our estimated costs for the extra workforce needed to fully implement the Ockenden recommendations.

In our letter, we noted that our initial estimate for the funding required to achieve the increase in staff numbers described by Ms Walton and Dr Morris in their evidence was a minimum of £250m in recurrent annual funding. We also noted that if shortfalls in neonatal nurses, maternity support workers and anaesthetists were to be included, the total annual extra recurrent funding required could be as high as £400m.

Calculating the cost of workforce expansion of this nature requires complex and detailed calculations. There is an element of estimation involved, especially as different organisations have different ways of calculating this type of estimated figure. This is why we felt it prudent to include a range in our letter to you.

As requested, please find our rationale for these figures in appendix one below but please note the caveats above!

Yours sincerely

Chris Hopson

Chief Executive NHS Providers

Appendix one: maternity workforce expansion cost calculations

Excluding community sexual and reproductive health doctors, NHS Digital’s workforce statistics showed that in September 2020 there were 2,480 consultants working in Obstetrics and Gynaecology. To increase this number by 20% would require an additional 496 consultants.

The basic salary for consultants currently ranges from £82,096 to £110,683. The midpoint in this range is currently £98,477 and is a useful figure to use to allow for pay progression. This does not account for additional payments which would be given for enhanced hours, wait list initiatives, or other contractual elements of work. However, we can assume as a starting point that the basic salary cost for 496 consultants would be:

£98,477 x 496 = £49m (£48,844,592)

Note that consultant on-costs vary depending on project, grade and pension scheme, however we understand from trusts that these can range from 20% to 30%. We take the lower figure in this calculation as an illustration. When applied to the assumed basic salary cost, this brings the figure to:

£48,844,592 x 1.2 = £59m (£58,613,510,40)

Local clinical excellence awards (CEA) require a minimum investment of 0.3 per FTE consultant. The minimum investment needed for an additional 496 consultants would be 0.3 x 496, equivalent to 148.8.

The maximum CEA level currently available is valued at £36,192. Award levels and allocations vary between location and year, but we can assume as a starting point that the CEA cost for 496 consultants would be:

£36,192 x 148.8 = £5m (£5,385,369.60)

The cost of training a doctor should also be considered. Although trusts would seek to fill posts with doctors emerging from the training pipeline, given a need for a permanent increase in establishment, we would need to increase training numbers accordingly. We assume a staggered approach to this over a period of five years of undergraduate training.

The cost of training a doctor through medical school in the UK was estimated in 2016 to be £160,000. This figure will have changed, but we can assume a minimum inflationary increase of 1.5% per year across the 5 years since 2016. Therefore, we estimate the total cost of training a doctor to foundation level in the UK to be in the region of:

£160,000 x 1.0155 = £172,365.44

Excluding the pipeline, training costs for 496 additional obstetric consultants is therefore likely to be well in excess of:

(£172,365.44/5 x 496 = £17m (£17,098,651.648))

Note this estimate does not include the cost of postgraduate medical training (foundation and specialty training) to the government for a doctor.

£81m.

Midwives

The maximum basic salary for midwives at the top of band 6 is currently £37,890. This figure does not account for additional payments which would be given for other contractual elements of work. However, we can assume as a starting point that the basic salary cost for 3,000 additional midwives would be £37,890 x 3,000, equivalent to £113,670,000.

We understand from trusts that on-costs will vary for nursing staff depending on a variety of factors, with a range of between 23% and 30%. For this calculation we are taking the lower range figure as an illustration. When applied to the assumed basic salary cost, this brings the figure to:

£113,670,000 x 1.23 = £140m (£139,814,100)

As with doctors, the cost of training midwives should also be considered. In March 2019, the Government announced plans to train more than 3,000 extra midwives over four years. With the HEE budget for 2021/22 confirmed in last November’s spending review, we will assume that all costs of training for the first three years of HEE’s March 2019 maternity workforce proposals have been budgeted for.

HEE estimates that training place increases from 2019/20-2021/22 will eventually increase the number of midwives in the workforce by 1,450 FTE staff. Given the scant evidence of improvement in retention and completion of training in recent years, we anticipate that ongoing funding will be required to reach the second half of this plan’s target increase, and to continue to grow the midwifery workforce in the future.

We have assumed the cost of training a midwife is similar to a nurse, estimated at

£51,000 in 2015/16. We can estimate the overall cost to have increased by inflation (1.5% per year across the 5 years since 2016), however the cost to the government is lower given the removal of the bursary and eventual introduction of training grants (the “learning support fund”) since then leaves part of the financial burden with students:

£51,000 x 1.0155 = £54,941.48

£54,941.48 - £12,750 (maximum student loan cost over 3 years) = £42,191.48

We assume a staggered cost over a period of three years of undergraduate training. Excluding the pipeline, training costs for 1,500 remaining additional midwives is likely to be around:

£42,191.48/3 x 1,500 = £21m (£21,095,740)

Anaesthetist consultants

The Royal College of Anaesthetists has recorded a workforce gap of 11.8%, equivalent to 1,054 FTE consultant anaesthetists, with a proportion of those specialising in obstetrics or otherwise spending part of their time in maternity care. 680 of these posts are already funded, leaving an unfunded gap of 374.

The basic salary for consultants currently ranges from £82,096 to £110,683. The midpoint in this range is currently £98,477 and is a useful figure to use to allow for pay progression. This does not account for additional payments which would be given for enhanced hours, wait list initiatives, or other contractual elements of work. However, we can assume as a starting point that the basic salary cost for the 374 unfunded consultants would be:

£98,477 x 374 = £34m (£34,171,519)

To note: consultant on-costs vary depending on project, grade and pension scheme however we understand from trusts that these can range from 20-30%. We take the lower figure in this calculation as an illustration. When applied to the assumed basic salary cost, this brings the figure to:

£34,171,519 x 1.2 = £41m (£41,005,822.80)

Local clinical excellence awards (CEA) require a minimum investment of 0.3 per FTE consultant. The minimum investment needed for the 374 unfunded consultants would be 0.3 x 374, equivalent to 112.2.

The maximum CEA level currently available is valued at £36,192. Award levels and allocation vary between location and year, but we can assume as a starting point that the CEA cost for 374 consultants would be:

£36,192 x 112.2 = £4m (£4,060,742.40)

Excluding the pipeline, and using the same approach to consultant obstetricians above, on-going training costs for additional anaesthetic consultants is likely to be in excess of:

£172,365.44/5 x 374 = £13m (£12,892,934.912)

for an estimated average 17.5% of time spent in obstetrics, the cost in terms of provision of maternity care is estimated as £10m.

Neonatal nurses

Neonatal care is provided by multidisciplinary teams, comprised of nurses, neonatologists, AHPs (including dieticians, pharmacists and speech and language therapists), clinical psychologists, nursery nurses and a range of non-clinical support staff (including administrative and housekeeping roles). There are, therefore, many different staffing groups which need consideration in terms of neonatal care workforce figures. This calculation focuses on neonatal nurses specifically.

In 2017, the total neonatal nurse shortfall was 2,263, with 1,791 of those needing to be filled in order to meet activity levels at that time. The number is likely to have changed now, but provides a useful starting point. This shortfall was found to be concentrated around band 5 to band 6 nurses. Assuming an even split of the necessary 1,791 nurses, we have based our calculation on this cohort of the shortfall being comprised of 895 band 5 nurses, and 896 band 6 nurses.

The maximum basic salary for nurses at the top of band 5 is currently £30,615. It must be noted that this figure does not account for additional payments which would be given for other contractual elements of work. However, we can assume as a starting point that the basic salary cost for 895 additional band 5 neonatal nurses would be

£30,615 x 895, equivalent to £27,400,425.

We understand from trusts that on-costs for nursing staff will vary depending on a variety of factors, with a potential range of 23% and 30%. For this calculation we are taking the lower range figure as an illustration. When applied to the assumed basic salary cost, this brings the figure to:

£27,400,425 x 1.23 = £34m (£33,702,522.80)

The maximum basic salary for nurses at the top of band 6 is currently £37,890. This figure does not account for additional payments which would be given for other contractual elements of work. However, we can assume as a starting point that the basic salary cost for 896 additional band 6 neonatal nurses would be £37,890 x 896, equivalent to £33,949,440.

With the additional 23% for on-costs as above, this brings the figure to:

£33,949,440 x 1.23 = £41m (£41,757,811.20)

We can calculate the costs of training for additional neonatal nurses in a similar manner to midwives (above), albeit without the impact of a specific recent funded increase in training posts for this specialty.

We assume a staggered cost over a period of three years of undergraduate training. Excluding the pipeline, training costs for 1,791 additional neonatal nurses is likely to be around:

£42,191.48/3 x 1,791 = £25m (£25,188,313.56)

Maternity Support Workers

In 2016, HEE set guidance that the skill mix of midwives and maternity nurses to Maternity Support Workers (MSW) should stay at 10:1. To support the proposed uplift in midwives and neonatal nurses (a total of 4,179) we have also costed a corresponding uplift in the maternity support worker workforce. Based on the HEE guidance skill mix this would equate to an additional 418 support workers. MSWs are generally employed at band 3 and band 4. Assuming an even split, we have based our calculation on the shortfall being comprised of 209 band 3 MSWs, and 209 band 4 MSWs.

The maximum basic salary at the top of band 3 is currently £21,142. It must be noted that this figure does not account for additional payments which would be given for other contractual elements of work. However, we can assume as a starting point that the basic salary cost for 209 additional band 3 MSWs would be £21,142 x 209, equivalent to £4,418,678.

We understand from trusts that on-costs will vary for nursing staff depending on a variety of factors, with a potential range of 23% and 30%. For this calculation we are taking the lower range figure as an illustration. When applied to the assumed basic salary cost, this brings the figure to:

£4,418,678 x 1.23 = £5m (£5,434,973.94)

The maximum basic salary at the top of band 4 is currently £24,157. This figure does not account for additional payments which would be given for other contractual elements of work. However, we can assume as a starting point that the basic salary cost for 209 additional band 4 MSWs would be £24,157 x 209, equivalent to

£5,048,813.

With the additional 23% for on-costs as above, this brings the figure to:

£5,048,813 x 1.23 = £6m (£6,210,039.99)

Totals

Our assumed total cost for a 20% increase in obstetric consultants is £81m. Our assumed total cost for 3,000 additional midwives is £161m.

Our assumed total cost for the obstetrics element of the 374 unfunded anaesthetist consultants identified by the Royal College of Anaesthetists is £10m.

Our assumed total cost to address the 2017 necessary neonatal nurse shortfall of 1,791 is £100m.

Our assumed total cost to address the Maternity Support Worker shortfall of 418 is

£11m.

Our estimated cost for a 20% increase in obstetric consultants and 3,000 additional midwives is around £242m (including an estimate of on-costs and some training costs, but not including CPD and recruitment efforts for midwives). We have rounded up to £250m to account for additional costs we cannot specifically account for (including the cost of postgraduate medical training for obstetric consultants) to allow for the high likelihood of further costs due to additional contractual elements of work.

Our estimated cost to address the group of aforementioned maternity workforce numbers is £363m (including an estimate of on-costs, but not including CPD and recruitment efforts for midwives, neonatal nurses, or MSWs). We noted that this figure could rise to as much as £400m, to account for additional costs we cannot specifically account for (including the proportional cost of postgraduate medical training for consultant anaesthetists) to allow for these additional potential needs.

March 2021