Written evidence submitted by Bupa Global & UK (RTR0130)
- Bupa Global & UK (BGUK) is one of the UK’s leading providers of health insurance, healthcare, dental care and aged care. 29,000 people work on our behalf in the UK, across our businesses. While we have workforce challenges across all of them, they are most acute in our health and care provision businesses.
- Bupa Dental Care is a leading provider of private and NHS dentistry in the UK. We care for 2.4 million patients every year in our 470+ dental practices across the UK and Ireland. In England, during 2021 we have delivered 2.25m NHS appointments.
- Bupa Care Services cares for around 6,800 residents in 123 care homes, and ten retirement communities offering independent and assisted living.
- Bupa Health Services comprises 49 health clinics, and the Bupa Cromwell Hospital, a complex care hospital in London that provides care for insured, self-pay, NHS and international patients.
- Like many employers, Bupa is currently facing a challenging workforce picture, both in terms of retaining existing staff and bringing new staff into the business. In part this is reflective of the wider economic picture of high employment, the welcome success of the furlough scheme in keeping individuals in existing employment, and the end of the EU Settled Status scheme and more generally the end of free movement of workers, likewise the wider impact of Covid has had an effect on our turnover of staff.
- However, our business faces much more long-standing workforce challenges which have long predated the pandemic. This is especially true of our health and care provision businesses where staff shortages pre-Brexit were exacerbated by the loss of access to EU labour pools and then further impaired by the pandemic, which has had a considerable impact on our staff.
- Across our businesses, we face significant challenges in recruitment and retention of our highly skilled staff. In some cases this is owing to the failure of Government to invest in the sector and its services – such as social care and NHS dental contracts.
- At Bupa we are committed to working in partnership with the wider health and care sector to deliver the improvements to the recruitment landscape that are necessary, however currently the Government’s view of recruitment is siloed and focused mainly on the NHS. This fails to appreciate the interconnected nature of our health and care systems.
- Challenges in recruitment are especially acute for hiring nurses, dentists and into the social care sector.
- Changes to the immigration system since 2016 have had a significant impact on our ability to recruit, and while this has started to improve recently, with changes to the Shortage Occupation List, further change is necessary if health and care services are to operate at full capacity.
- We recognise that the creation of a pipeline of future workers is part of our obligation as an employer and have put in place significant investment in apprenticeships, training and career pathways across our services. Greater flexibility in the apprenticeship levy would be welcome in order to allow more effective and efficient use of this investment.
- One of the impacts of staffing shortages is an increased reliance on agency, which comes at significantly greater cost, while also at times reducing quality and continuity of care.
- Within dentistry, ultimately, a lack of NHS dentists or those willing to undertake NHS contracts means it is difficult, or impossible, to fulfil an increasing number of NHS contracts, and that patients cannot access NHS care.
- There is an opportunity to use the establishment of integrated care systems, and the creation of a social care workforce plan to look more holistically at the recruitment challenges across the health and care sector and establish partnerships which address these issues for the sector as a whole, rather than focusing on siloed approaches within parts of the sector.
Challenges facing recruitment of new staff in health and care
- The health, dental and social care sectors have been struggling with recruitment challenges for a long time and while this has been exacerbated by the pandemic, it was not caused by Covid. As such the solutions can often be longstanding and already well documented.
- That said, it is likely that health and care services will be managing the impacts of Covid for years to come, for instance additional testing and infection prevention and control measures. The additional pressures this puts on the workforce, both in terms of frontline staff time and additional compliance obligations must be recognised in funding settlements going forward.
- In some areas of our health and care provision business the Government has offered financial and other forms of support to help address immediate workforce challenges, such as the Social Care Workforce Recruitment and Retention Fund. While this is welcome, this support will only be a temporary measure and will not resolve the challenges in the long term.
- The care sector is concerned by the increasingly short-term nature of the funding, which previously operated over several months, but most recently has only been put in place for a one-month period. This makes planning staffing arrangements exceptionally challenging as there is little certainty about the long-term future of these funds.
- The health and care sector as a whole is committed to solving these problems itself where this is possible, through investing in talent pipelines, training and development opportunities and improving terms and conditions. However, there are areas where this is not possible without Government help and in some cases where Government intervention is necessary before this can take place.
- This is particularly the case in the social care sector, where increased investment is necessary before salaries can sustainably improve to a more attractive level. Currently the increases the Government have announced do not reach the level that the Health and Social Care Select Committee has estimated is necessary to meet rising demand while improving conditions for frontline staff. We look forward to the detail of the Government’s reform plans and hope that significant funding increases will follow.
- Intervention is also necessary in the dental sector where there is a particular issue where there are not enough new dentists joining the profession to meet the needs of the population. There are long standing recruitment issues, driven by unattractive NHS contracts, a lack of trainers and a variety of other challenges.
- The current training system does not encourage experienced dentists to become trainers. As a result, there are not enough Foundation and Performers List Validation by Experience (PLVE) dentists’ trainers. The application process to become a trainer is also costly. Incentivising dentists to become trainers will enable more dentistry students to complete their training.
- There was a large fall of 22% in new dentist registrations in the UK in 2017, as those registered with a UK qualification moved down by over a fifth (21.6%). While the number of dentists registered with the GDC has remained broadly the same, leading some to infer there is no shortage of dentists, these numbers do not account for those that remain on the register but are not delivering much or any dentistry in the UK.
- Furthermore, since the introduction of the 2006 NHS contract, the fees received by Associates for the delivery of UDAs have remained capped at the same level, but costs incurred by Associates and providers in the delivery of dental care, for example indemnity costs, have increased significantly.
- NHS contracts also place a high level of pressure on newly qualified dentists due to the requirement to meet targets while not being financially rewarding. This is driving individuals away from careers providing NHS dentistry and towards private dentistry and in some cases, out of the sector entirely. As such, like in social care, limited investment from Government is a core driver of recruitment and retention challenges.
Impact of the immigration system on recruitment and retention
- The Government’s new immigration system has caused significant challenges for health and care businesses seeking to recruit and retain staff from outside the UK.
- While the Health and Care Visa does assist in resolving some of the difficulties imposed by the Government’s new immigration system for some roles, the salary floor makes it impossible to use this as a means of recruiting for many roles, despite shortages in the UK workforce – such as for health and care assistants.
- The Government’s slow and initially negative response to the Migration Advisory Committee’s recent recommendations have also hampered recruitment.
- The addition of care workers and dental therapists to the Shortage Occupation List (SOL) is welcome however this alone is insufficient as it still leaves some roles off the SOL and, owing to the limitations of the Health and Care Visa, such as the salary threshold, simply adding roles to the list is insufficient to address the recruitment challenge.
- These welcome additions are only a step towards what is needed to tackle the sector-wide recruitment crisis, which would include adding dentists and dental nurses to the SOL.
- We hope that the upcoming Migration Advisory Committee review of the impact of ending freedom of movement in social care will trigger a review of restrictions on hiring into these roles, and a wider reassessment of the impact of migration restrictions on the whole health and care sector.
- The failure to recognise the existence of a dentist shortage in the UK makes it difficult for the MAC to recommend adding them to the Shortage Occupation List, therefore the first step in this case would be to alter the methodology by which shortage is assessed to take into account the fact that some dentists may be registered but not practicing.
- While we recognise the imperative to build and develop our pipelines of staff by investing in the training and development of the UK workforce – our work on this is discussed in a later section – this must be balanced by a recognition from Government that at times of staff shortage, training timelines are far too long to fill immediate vacancies.
- There are also an extraordinary number of regulatory and professional burdens placed on overseas dentists prior to allowing them to practice in the UK.
- EU dentists need to undergo one year of mentorship with a mentor dentist. There are limited numbers of dentists willing to be mentors, and the practices that need to train mentees most are the ones least likely to have dentists with the capacity to do so – for instance a dentist who is retiring owing to the stresses of NHS dentistry is unlikely to be willing to mentor an EU dentist to take his place.
- The specifications for mentor dentists are also arbitrarily strict and also vary by Local Area Team - commonly dentists must have undertaken four years NHS dentistry in addition to holding two years of experience at the training practice that the mentee will be based at. This variation, and the lack of transparency regarding regional variations, makes it difficult for consistent recruitment of these mentors to take place. This means it is hugely challenging to find mentorship locations for EU dentists in the areas where NHS dentistry requires the most support.
- EU dentists currently have recognition of EU titles until end of 2022, and unless new mutual recognition arrangements with EU countries are secured via the GDC, after that they will also need to go through the process for non-EU dentists outlined below. It is essential that a solution is found to ensure that EU dentists maintain their current mutual recognition arrangement before the end of this year, or face significantly worse recruitment prospects for dentistry, and therefore, even more restricted access for NHS patients.
- In the case of non-EU dentists, there are even more hurdles to overcome. They must go through the Performer List Validation by Experience (PLVE) process to practice in the NHS within the UK. This is a long, cumbersome process that varies between LATs and can take up to 2 years to complete.
- Non-EEA dentists must also complete the UK Overseas Registration Exam (ORE) or the Licence in Dental Surgery (LDS). There are limited places for both exams, which have a high failure rate and must be taken in the UK – an expensive undertaking for a graduate dentist. The 2020 Part 2 ORE was cancelled due to COVID-19 and has still not resumed, meaning over a year of potential intake has been lost.
- As LDS/ORE places are limited, often with more applicants than spaces, clinicians commonly must apply multiple times to sit their exams. After they’ve passed these, they are then required to find a practice with a role that can support them, with both the practice and the PLVE supervisor needing to be assessed/passed as fit to support a PLVE candidate.
- Only once these hurdles are complete can they apply for their provisional performer number to enable them to work in the NHS, under the guidance of their PLVE supervisor. The length of time this process takes makes attraction to the NHS system far more difficult.
Training and apprenticeships
- One of the areas we have made substantial investment in is apprenticeships and training. In 2021, we invested over £3.3m our apprenticeship programme and placed over 1,000 apprentices in our businesses, including more than 400 in our dental business and nearly 300 in our aged care services.
- Through schemes like this we are developing clear career paths for our frontline people and managers, including using lifelong learning and apprenticeships schemes to develop roles that have the greatest direct impact on those who rely on our services.
- In our aged care business, we have created a new role of Care Practitioner, sitting between senior carers and nurses, providing an enhanced career pathway for carers and providing support to nursing teams. We are proud that this was recognised at last year’s CIPD Management Awards where Bupa Care Services was a finalist in the ‘Best Apprenticeship’ category.
- In our dental services we have introduced a trainee nurse role to bring in and upskill dental nurses for the future. While this role is outside of the levy, this helps reduce the reporting and recording requirements, which can be onerous for some learners, while still offering a rigorous and rewarding training and development package.
- Furthermore, we are expanding this approach to include a Nurse Associate Apprenticeship in our Health Clinics business, which will help healthcare assistants make the transition into nursing roles.
Staff wellbeing and attrition
- The impact of the pandemic on the mental health and wellbeing of health and care workers is one that has been recognised over recent months, however the Government’s plans to help address this – such as those announced in the recent Build Back Better plan for health and care – are limited.
- From the outset we have supported our staff with internal resources and help, however it is welcome that the Government recognises that this is a challenge and must continue to invest in these kinds of support or risk further attrition from the health and care sector.
- There is a perception that the pandemic has only affected the mental health of those on the frontline of the fight against Covid, and while those frontline teams are the most seriously affected, the impact on mental health has not been exclusive to them.
- According to an NHS Digital poll, over half of all dentists regularly think of leaving dentistry. The most common reasons given are increasing expenses, declining income, and increased risk of litigation and the cost of indemnity fees. More than half of all dentists do not feel they are fairly paid by the current NHS contracts.
- This has been compounded by the current crisis, with dentists facing increased stress as a result of COVID-19 infection control procedures and increased patient frustration at lack of available appointments. A recent BDA study found that 72% of dentists stated that the lack of clarity over the government's imposed activity targets are having a high impact on their morale.
- While we wholeheartedly welcome and support the rollout of the Government’s vaccination campaign and fully recognise the rationale behind the proposals to mandate vaccinations, these proposals have and will continue to have an impact on recruitment and retention.
- In our businesses where the COVID-19 vaccine has already been mandated, we have seen a small but significant number of staff leave their roles, and it further limits our ability to recruit into these roles. That said, we recognise the rationale for a COVID-19 vaccine mandate owing to the high proportion of vulnerable individuals involved and the nature of the setting and provision.
- The operational, administrative and, ultimately, financial cost of compliance with a vaccine mandate is also significant and, in the case of social care, reporting is tied to access to Government support.
- We are concerned that the regulatory and administrative burden of ensuring compliance with vaccine mandates will outlast the support the government provides, placing yet another cost onto the heads of providers.
Shortages exacerbated by geography
- Location has a significant impact on staffing, as the recruitment market varies across the regions and nations in which we operate. It impacts us in three main ways.
- Firstly, the demographics of an area affect the availability of staff. In social care particularly, services are most likely to be established in areas of high demand, with large aging populations. This makes finding workers in those areas doubly hard, as the local labour pool is proportionately smaller. This forces us to cast a wider net in the search for staff.
- The variability of transport links is the significant factor in how regional variations cause difficulties for recruitment. By and large, areas which are more rural have worse transport connections. In such cases this can limit the number of applicants to those who either can drive themselves or who live in easy access of what public transport is available. This has a knock-on effect on health inequalities.
- Rural and coastal areas are also significantly harder to recruit new dentists into owing to the urban nature of all the major dental schools, which creates both a set of lifestyle expectations and personal connection with specific urban areas which require either increased financial reward or other incentives to offset.
- In order to try to mitigate against this, we have started at looking at rotating our employed dentists into areas of the most significant shortage, offering improved sponsorship of professional certification for those overseas dentists who agree to work in these areas.
- Finally, the third way location has an impact on staffing and recruitment is through specific issues within local labour markets, such as the presence of competitors or other large recruiters in the locality.
- Across our care homes, health clinics and hospital we are particularly struggling with a shortage of nurses. There are some recruitment challenges that are impacting nursing in particular, for reasons which are well established. These are causing a long lead time to recruit and more of a reliance on contingent workers when we can’t fill all roles with our permanent staff base.
- The combined impact of Brexit and the pandemic has been felt most significantly in this area, as some nurses have returned home rather than seeking settled status, especially as the pandemic induced restrictions on travel have reduced opportunities for those who remain in the UK to visit their families.
- In addition to our apprenticeship approach to increasing numbers of nurses long term, highlighted above, we are looking at specific recruitment campaigns focused on overseas trained nurses who have not applied for a PIN in the UK. Where possible, greater visibility of these kind of data in Government data sources would be a welcome improvement in understanding where to focus this kind of recruitment campaign.
- Our social care services in particular suffer from being unable to compete with the NHS in terms of pay and conditions for nurses. While the NHS has the Agenda for Change, social care does not have a comparison, as such social care struggles to compete for talent. A more holistic approach to workforce planning would be a welcome step to alleviate this challenge.
- One particular challenge employers face is the comparative challenge in securing a PIN for overseas qualified nurses. A shift towards more mutual recognition of overseas qualifications, on a permanent basis, would be advantageous, especially with countries where the nursing education system is similar, and qualifications are similarly rigorous.
The impact of agency
- When vacancies cannot be filled this increases our reliance on agency and bank staff. We attempt to reduce this reliance on such temporary staffing routes through overtime and redeployment of staff (where possible within the confines of the Government’s staff movement restrictions). However, ultimately this is not always possible and we as a both an aged care and hospital provider are reliant on agency and bank staff to fill gaps.
- This has an impact on service delivery both in terms of the continuity and quality of care but also in terms of our residents’ overall wellbeing through the personal connection between residents and staff, which are built over long periods between our permanent staff and service users and which are beneficial for both staff and service users, especially in settings such as care homes. This is not always replicable with agency and bank staff.
Integrated Care Systems
- Integrated Care Systems are an opportunity for the health and care sector to look at recruitment challenges both more regionally and more holistically. They offer the chance for regional challenges – such as transport or a higher cost of living – to be reflected in workforce policy. They also offer the chance for a wider view of workforce policy that encompasses the NHS, ASC and other health and care providers.
- We would encourage greater representation of ASC and dentistry on ICS boards. Currently ASC is only represented by Local Authorities, with no provider voice, and dentistry has even less representation than this.
- Furthermore, we would also welcome the explicit creation of workforce working groups within ICS which can look holistically at the challenges faced in their communities and work with the sector as a whole to address them.
A Health and Care People Plan
- We are proud of the role that we play within the health and care system, supporting the NHS and providing much needed adult social care and NHS dentistry across the country. It is right that the NHS has a comprehensive people plan, and we have long supported the implementation of a similar plan for ASC.
- We would also propose the creation of a holistic, sector wide health and care people plan which recognises that the challenges faced by the NHS and the private healthcare sector are interlinked and interdependent; solutions for the NHS will also have an impact on our ability to support the wider health and care sector’s work.
- This holistic approach would also recognise the interdependence between sectors such as ASC and the NHS, where staff move between NHS and ASC roles frequently and a siloed approach is unhelpful.
- Furthermore, such a plan should recognise the role non-NHS providers could play in wider training and development schemes, such as specialist aged care nursing training which would have application both in the NHS and ASC.
- Finally, a holistic approach would be able to consider the impact of some of the challenges around dentists highlighted above.