Trade Union Congress – Written evidence (NHS0084)

Key Points

•      The TUC believes that the starting point for any discussion should be an assertion of the benefits that derive from a universal, accessible service delivered free at the point of need and funded through general taxation. The long-term funding options must flow from that starting point.
•      The TUC does not believe that the current funding settlement for the NHS is realistic, with average annual increases of less than 1 per cent over a ten year period failing to keep pace with demand, resulting in an alarming deterioration of provider finances and a negative impact on service quality.
•      Social care funding has fared even worse with a 9 per cent real terms cut in funding since 2010 leading to over 400,000 fewer older people getting the paid-for care that they need and forced to turn to over-stretched NHS services or informal care instead.
•      The TUC believes that the healthcare system of the future needs to deliver a more integrated service across social care, primary and secondary, community, mental health and public health services in order to design and deliver services that meet the needs of patients and drive productivity and innovation.
•      The increasing need for health and social care integration means that both sectors must be considered as part of this review. The TUC believes there is merit in looking at the recommendation of the Barker Review for a “single ring-fenced budget for health and social care that is singly commissioned and within which entitlements are more closely aligned”.
•      Providing health and care funding that provides free entitlements for all those with moderate to critical needs will entail a considerable increase in public spending but the work by the Barker Review and others suggests that this is both affordable, given the right political choices on taxation, and will have positive benefits on service users, their families, wider society and the economy, with the OECD pointing to a wide range of health and economic benefits derived from increased healthcare spending.
•      The TUC believes that general taxation is the most appropriate model for funding a universal health and social care system in order to provide equality of access and fair funding without recourse to charges or means-testing that run counter to the founding principles of the NHS.
•      This means that increased public spending of this order will require a serious and honest approach to the way that taxation will be used to lever the required resources. The TUC may not agree with all the tax and spending recommendations made in the Barker Review, but we agree that the government should explore a range of tax options that can be used to raise the required investment in public services as part of a wider process of tax reform.
•      We would also make the fundamental point that efficiency, innovation and integration is best promoted through a model of public ownership that eradicates the additional costs and the dysfunctional competition and fragmentation created by marketisation – most obviously exemplified by the reforms of the coalition government of 2012.
•      There is little doubt that proposals to provide greater integration of services across and within the health and social care system, in order to boost productivity, innovation and provide tailored services to people with complex and long-term needs, will have significant impact on the health and social care workforce.
•      In addition to meeting the challenges of the future direction of travel, there are a number of existing pressures that need addressing in order to both meet the needs of the current system and help facilitate the changes required to develop the workforce of the future – including staff shortages in a number of occupational groups, problems with recruitment and retention, workforce development and providing training routes into the NHS.
•      In social care there are also very significant challenges in providing a workforce that is empowered, trained and equipped to deliver the changes required in an integrated health and social care system of the future.
•      Given both the demands of the future proposals and existing pressure points and challenges across the health and social care workforce, it is imperative, as health unions argue, that we have a joined up workforce strategy that works at a national, regional and local level. However, workforce planning is a major gap.
•      The TUC believes that there is a need for a workforce strategy that harnesses the NHS Staff Council refresh of the Agenda for Change pay structure, which is aligned with the initiatives in the national and regional partnership forums on culture, wellbeing and leadership and which engages trade unions in service and workforce transformation. 
•      A workforce strategy should focus on:
• The impact of wage stagnation on recruitment and retention, morale and motivation
• Future recruitment, including student commissions
• Retention of existing staff including consideration of career progression, training opportunities, health and wellbeing
• Pay and reward of staff delivering NHS services across the UK, across health and social care and those affected by transfer out of the NHS
• Positive approaches to improve productivity, including: better rates for bank and overtime work; implementing the recommendations of the Boorman Review; and investment in staff.

Taking into account medical innovation, demographic changes and changes in the frequency of long-term conditions, how must the health and care systems change to cope by 2030?

The challenge of meeting the demand for health and social care from a growing and ageing population with increasing frequency of long-term conditions and co-morbidities is well documented.  According to the Lords Select Committee report Ready for Ageing, England will see a 51 per cent rise in those aged 65+ and a 101 per cent increase in those aged 85+ from 2010 to 2030 which, in the words of the committee “will have a profound impact on a wide range of public services”[1].

Evidence, however, shows that as well as living longer we are generally staying healthier and we would caution against exaggerating the impact of increasing numbers of older people on the NHS. As the King’s Fund point out, increasing demand driven by demographic change is greatly exceeded by increased costs of the provision of healthcare through technological change which both increases the supply and cost of care, rising patient expectations and the fact that, as a ‘luxury good’, health spending increases at a greater rate than GDP[2].

The TUC believes that the starting point for any discussion should be an assertion of the benefits that derive from a universal, accessible service delivered free at the point of need and funded through general taxation. The funding options must flow from that starting point.

Furthermore, we agree with the point made by the Nuffield Trust in oral evidence to the Committee that with the demographic changes and the blurring of boundaries between health and social care, we need to consider both the future sustainability of the NHS and social care at the same time.

We agree with Kate Barker’s assertion that the current settlement for social care “lacks transparency, is inefficient, puts too much weight on individual rather than collective responsibility and is not equitable” and that “most importantly, the present situation does not respond sympathetically to the needs and preferences of users and their carers”[3].

The TUC has had a long-standing commitment to a national social care service, free at the point of use and funded through general taxation. As such, we believe there is merit in looking further at the King’s Fund conclusion that “England needs to move towards a single ring-fenced budget for health and social care that is singly commissioned and within which entitlements are more closely aligned”[4].

The TUC believes that the healthcare system of the future needs to deliver a more integrated service across social care, primary and secondary, community and mental health services and public health in order to design and deliver services that meet the needs of patients and drive productivity and innovation - and that these integrated services should be funded through general taxation.

This will entail a considerable increase in public spending but the work by the Barker Review and others suggests that this is both affordable, given the right political choices on taxation, and will have positive benefits on service users, their families, wider society and the economy, with the OECD pointing to a wide range of health and economic benefits derived from increased healthcare spending[5].

The Barker Review makes the important point that the costs of meeting the care challenge do not go away just because they are not financed from the public purse – there needs to be an honest approach to how we meet this challenge as a society rather than relying on individual families to bear the financial cost and fill the gaps through the provision of informal care that many struggle to provide.

As the Barker Review states “overall spending on the cost of care for older people will inevitably rise given the ageing population. The question is not whether this money is spent. It is about where the cost fall – on collective provision through public expenditure, or on those individuals and families who are unlucky enough to have very high care needs”. Kate Barker herself rightly points out “more generous public funding is needed if we aim to be a civilised 21st-century society”.[6]

To what extent is the current funding envelope for the NHS realistic?

Despite the then Chancellor George Osborne’s claims that the 2015 Spending Review delivered the “biggest ever commitment to the NHS since its creation”[7], the TUC does not believe that the current funding envelope for the NHS is realistic.

As research from the Health Foundation points out “the NHS in England is currently halfway through the most austere decade in its history” with the £4.5bn real terms increase in health funding provided in the 2015 Spending Review meaning that real terms annual increases will have been an average of 0.9 per cent from 2009/10 to 2020/21 – “the lowest ever rate of funding growth over a 10 year period”[8]. This contrasts with rising healthcare costs of 4 per cent and an historic average increase for the NHS of 3.8 per cent.

This has been reflected by a sharp increase in NHS provider deficits, reaching a record £2.45bn at the end of 2015/16 with 95 per cent of acute trusts in the red. The reason is plain - the costs of delivering care rose faster at 2.2 per cent than the income that providers received at 2 per cent[9]. Much of this can be attributed to rising staff costs, particularly agency costs, to meet shortfalls in safe staffing ratios and reductions in average tariff payments.

Over the lifetime of the last parliament, tariffs were cut across the board by an average of 10 per cent. But many more have received larger cuts, research by False Economy for the TUC and UNISON found that a quarter of hospital treatments have been cut by over 40 per cent, almost one in ten have had cuts of over 70 per cent[10].

Despite the best efforts of NHS staff, the deterioration in NHS provider finances has led to adverse impacts on the quality of services. This has impacted on a wide range of services, including in A&E, cancer care and mental health services:

•      Just over 2 per cent of patients waited over 4 hours for treatment in A&E in early 2010. Today, this number has risen to around 10 per cent[11]. In January of this year, A&E performance reached its worst level on record, with ambulances frequently queueing over 30 minutes and record numbers of patients waiting for hours on trolleys[12].
•      Since 2006, patients have expected to be treated within 62 days of an urgent cancer referral from their GP. NHS providers are expected to meet this target for 85 per cent of patients. The figure has dropped from 86.7 per cent in April 2010 to 82.1 per cent this summer, with the NHS missing the target for six consecutive quarters now.[13]
•      Since 2009 there has been a 12 per cent reduction in the number of beds available to mental health patients, the Royal College of Psychiatrists said that on one day in 2014 there were no beds available at all in England. ‘Out of area placements’ rose 23 per cent last year with patients facing journeys of up to 370 miles for beds[14]. Alongside the reduction of in-patient care, there has been a reduction in community based services, while referrals have increased by [15] per cent.

Calling for “urgent action to increase capacity in A&E departments” Dr Clifford Mann of the Royal College of Emergency Medicine paints a grim picture of staff on the front line, explaining that “it is now routine for many staff to arrive at work faced with congested and overcrowded departments in which it is impossible to deliver best care. Similarly, many leave work, hours after their agreed finish time, exhausted by the scale of the task.”[16]

It is worth reminding ourselves that the Wanless Review in 2002, the last systematic review of the future funding requirements of the health service, concluded that increased health spending was required in order to address the care issues that had emerged through previous years of underinvestment. The Review concluded that “the UK must expect to devote a significantly larger share of its national income to health care over the next 20 years. It has projected the likely costs of reversing the significant cumulative underinvestment over past decades, to catch up with the standards of care seen in other countries and to deliver a wide-ranging, high quality service for the public and individual patients”.[17]

Social care funding has fared even worse. Between 2009/10 and 2014/15, adult social care received a real terms funding cut of 9 per cent. This has led to a fall of more than 25 per cent in the numbers of people aged over 65 receiving community-based, residential and nursing care services. That’s 400,000 fewer older people getting the paid-for care that they need and forced to turn to over-stretched NHS services or informal care instead[18].

Local authority funding is set to decline still further as a result of the Spending Review, with very different outcomes for local authorities with low council tax and business rate incomes, who may be more dependent on the central government grants that will be halved by 2020. The 2 per cent precept to council tax will, at best, raise £2bn by 2020 – against a predicted funding gap twice that size[19]. Local authorities with high levels of council tax income could increase their social care spending by up to four times as much as more grant-reliant authorities through the precept. The postcode lottery for older people reliant on paid-for care is going to get a whole lot worse, with huge repercussions on local NHS services – ResPublica predicts additional costs of up to £3bn as a result.[20]

The current review of local government funding reform also raises the prospects of a widening inequality between local authorities, as the effects of the replacement of formula grant with 100 per cent retention of business rates may well lead to greater disparities in income from 2020. Not only could this lead to a widening of income between local authorities but it will also mean that local authority income, and therefore funding for social care, will be entirely reliant on the extent or limitations of business growth in the local area - a situation made more precarious by the removal of large numbers of small businesses from the rates system altogether – as opposed to the needs of the local population.

The business rates review is also introducing the prospect of local authorities taking over responsibility for the administration of Attendance Allowance (AA), which we believe could lead to: reductions in the number of people accessing the benefit (as local authorities may use the non-ring fenced budgets to plug gaps elsewhere); varieties in the provision of AA, exacerbating post-code lotteries; and may restrict the freedom of choice that recipients currently have on the use of AA.

The government may point to the funding deal struck with NHS England as part of the Five Year Forward View, arguing that the £8bn it set out for NHS England in the Spending Review was in line with the funding requirement of the Forward View. However, there are four important points to make on this.

First, taking into account the 21 per cent cut to non-NHS England budgets[21], including training and public health, the actual real terms increase from 2015/16 to 2020/21 is closer to £4.5bn.

Cuts to public health will also weaken exactly the kind of local preventative interventions in areas such as obesity, sexual health and well-being that we need to manage demand on health services over the long run. Reducing funding to public health initiatives that keep people away from stretched GPs and hospitals is a false economy. For example, it is estimated that the cost to the UK economy of overweight and obesity was estimated at £15.8 billion per year in 2007, adding £4.2 billion in costs to the NHS[22].

Second, £8bn requested by the NHS Forward View formed part of a funding call that was dependent on delivering significant year on year productivity gains, which were dependent on investing in new care models and sustaining social services. New care models require time and investment to work and the clinical outcomes and efficiencies will not be known for some time yet. And we have seen that social care continues to face funding cuts.

Third, there remains a great deal of scepticism about the ability of the NHS to deliver the £22bn efficiency savings earmarked in the Forward View in the time required. Around three quarters of savings found in the last 5 years in the NHS have come through cuts to tariffs and capping NHS workers’ pay. But neither are sustainable going forward, with many hospitals in dispute over tariff reductions and recruitment and retention and morale problems intensifying across all staff groups in the NHS.

While the long term solution may lie in productivity gains largely delivered through new ways of working with a greater focus on prevention and integration, we should caution against glib assumptions that greater integration and prevention will inevitably lead to significant savings even though it might be the right thing to do for patients.

A report[23] by a commission put together by the Health Service Journal labelled NHS England’s prediction of £22bn productivity gains as “a heroic assumption” and found “no evidence” to support assumptions that integration between health and social care would lead to significant cashable savings.[24]

They cite key research looking at integration across different countries, and found no evidence of reductions in hospital admissions or increased cost effectiveness resulting from integration, although there were better outcomes for patients.[25] So while integration remains an essential, albeit often elusive, aspiration for improved health services, it may prove to be far from the silver bullet that many in NHS England and the Treasury are hoping it is.

Likewise, potential savings set out in the Carter Review worth up to £5bn represent only a quarter of the savings required in the Forward View. As the Health Foundation state “there is no clear guidance about how the NHS will achieve the full savings amount required”[26].

Fourth, the Forward View was supposed to start from a balanced budget but with provider deficits in the region of £2.45bn and NHS employers meeting increasing pension and NI costs, much of the money provided for sustainability and transformation across the health service is likely to be focussed on the former rather than the latter.

This means that funding is being taken away from initiatives to implement the new models of care that are supposed to be the key to achieving more efficient and integrated services of the future. It was reported just this week that vanguard projects are having to be scaled back as they have received less than a third of the anticipated funding this year.[27]

There are also increasing concerns that the Sustainability and Transformation Plans established in order to achieve better coordination and collaboration between commissioners and providers in local health economies are driving through reconfigurations and cuts to services based on financial, rather than clinical, imperatives.[28]

The TUC shares the concerns voiced by Chris Ham of the King’s Fund who, commenting on bed reduction proposals in North West London, STP stated that “It is hard to see how this can be done with demand for hospital care rising inexorably, bed occupancy already at eye-wateringly high levels and services outside hospital not in a position to provide an alternative after years of under-investment”.[29]

Does the wider societal value of the healthcare system exceed its monetary cost?

The OECD lists a range of population health benefits that have accrued to OECD countries in recent decades, citing a 50 per cent cut in premature mortality since 1970, a ten year increase in life expectancy at birth since 1960 and large reductions in child mortality.

Over a shorter timescale, the OECD point to significant improvements since the mid-90s in breast cancer survival rates, improvements in cardio-vascular health and increased survival and lower disability rates following strokes.

The OECD states that there are a range of factors that have contributed to these successes but attributes much of this to investment in healthcare, stating that “up to 40 per cent of the increase in life expectancy since the early 1990s could be due to more and better health spending”.  Furthermore, their report points to increased access to health care services, with OECD countries achieving “universal or near universal coverage for a range of core services”.

Finally, the OECD also states that “the health system contributes to economic performance. It is a major employer – it accounts for nearly one in every ten jobs in OECD countries; health spending helps stabilise the economy in times of crisis, and it is a contributor to the productive capacity of OECD economies”[30]

The role that health care spending plays in supporting health, well-being and an individual’s productive capacity has knock on effects for other parts of government spending. The Work Foundation report that “in 2009, in the region of 11,000 people in England and Wales were enabled to return to work by hip replacement surgery, saving the UK welfare system £37.4m each year of their working lives”.[31]

According to the King’s Fund, health spending can have significant wider economic impacts. Evidence suggests that the average multiplier effect of public health care spending across a range of countries has been about 3.6 – larger than almost all other categories of spending[32].  While there are no NHS-specific figures, but the King’s Fund report estimates the NHS spending multiplier to be in the range of two to four.[33]

We would add one final point. The NHS forms an integral part of our cradle to grave welfare system that does not just provide key services to people but plays a fundamental role in social cohesion, binding our communities together, securing long-term investment and support for local economics as well as acting as an anchor for institutions in our local communities.

What funding model would best ensure financial stability and sustainability without compromising the quality of care?

As we set out above, the TUC supports a model of universal accessible services, free at the point of use and funded through general taxation. Given that the Commonwealth Fund placed the UK in overall first place in terms of efficiency, defined as a system that maximises “the quality of care and outcomes given the resources committed, while ensuring that additional investments yield net value over time”[34] there seems little merit in reinventing the NHS.

We think that there is merit in exploring the recommendations of the Barker Review that, in order to address the lack of alignment in entitlements to health and social care, in funding and in organisation, there should be a single ring-fenced budget for a national health and social care system, jointly commissioned.

The Barker Review estimates that a model of this kind, with provision of free social care covering moderate as well as critical and substantial care needs for the over-65s, would entail an increase of spending from the current level of around 9.7 per cent to 11.3 per cent by 2025[35]. This would involve not only a large increase in the amount of spending on, but also an increase in, the proportion of public spending going to health and social care.

However, the TUC would make the following 3 points, echoing the Barker Review.

First, that if GDP were to grow in line with OBR projections (at the time of the review in 2013), this would still be affordable. Health and social care spending would be in the region of £204bn in 2025 out of a total GDP estimated to have grown to £1,800bn. As the Review states “public spending on health and social care would be taking a larger share of a much larger cake. The economy would be around more than one-third bigger, and that would still leave more money in real terms to spend on other things”[36].

Of course GDP may well fail to grow in that order, particularly as the impact of the UK’s exit from the European Union becomes fully realised. Timescales for the full phasing and implementation of this funding model may need to be adjusted accordingly – free social care may be phased in at first for critical and substantial need, as one example.

Furthermore, the funding model must take into account scope to restore pay to levels that provide fair remuneration to NHS and social care staff and addresses growing recruitment and retention problems. Pay restraint cannot be factored among other things being equal within this model. Any model of service integration must also deal with harmonisation and levelling up between of two very different workforces, with different skills mixes and employed on different terms and conditions - the cost of which needs to be built into any future modelling.

Second, public spending as a proportion of GDP on health and social care in the region of 11 – 12 per cent of GDP would place the UK in line with the levels provided by a number of leading OECD countries currently. As Barker points out, England is not a big spender on health and social care in comparison to other leading countries, spending 1 per cent of GDP less on health than France, Germany, Denmark, the Netherlands, Austria and Canada. And the UK spends considerably less than others on social care, with 0.9 per cent of GDP compared to 2.3 per cent in the Netherlands, 2.2 per cent in Denmark and over 1.1 per cent in New Zealand, Canada, Belgium and France[37].

This suggests that while challenging, the figures proposed by the Barker Review are not unrealistic or unfeasible.

Third, the TUC believes that general taxation is the most appropriate model for funding a universal health and social care system in order to provide equality of access and fair funding without recourse to charges or means-testing that run counter to the founding principles of the NHS.

This means that increased public spending of this order will require a serious and honest approach to the way that taxation will be used to lever the required resources. The TUC may not agree with all the tax and spending recommendations made in the Barker Review, but we agree that the government should explore a range of tax options that can be used to raise the required investment in public services as part of a wider process of tax reform.

We believe that the current strong levels of support for tax increases as the preferred option for raising funds for the NHS would extend to a broader health and social care system if political leaders were able to have an honest and informed discussion with the public.

In the “national debate” on the future of care and support launched by the Labour administration in 2009, there was strong support for a tax-funded national care service with high levels of support for taxation that was seen as “the most equitable solution and that a collective approach to funding would pool risk and ensure that individuals were not left unable to pay for their care and support”. When participants were asked to consider who should bear the burden of the likely increase in the cost of social care, 82 per cent opted for “everyone in society” compared 8 per cent to “individuals who need care and support” and 8 per cent for “families of individuals who need care and support”.[38]

The TUC would also make the fundamental point that efficiency and the innovation and integration is best promoted through a model of public ownership that eradicates the additional costs and the dysfunctional competition and fragmentation created by marketisation – most obviously exemplified through the reforms of the coalition government in 2012.

We note that in many areas, from the joint commissioning board in Greater Manchester, to vanguard projects and, indeed, STPs (in theory), the direction of travel is away from the competitive, fragmented model brought in by the 2012 Health and Social Care Act towards a greater focus on collaboration and cooperation across health economies. A national, integrated service under public ownership would be the most appropriate vehicle for taking forward this approach in a sustainable way for the future.

Furthermore, it could provide significant efficiency savings. While there are several estimates of the costs of marketisation in the NHS, the Centre for Health and the Public Interest provide a conservative figure of £4.5bn a year.[39]

Should the scope of what is free at the point of use be more tightly drawn?

The TUC would oppose any moves to restrict the provision of services (other than through the evidence based guidance and advice provided by NICE) or introduce charges with the aim of either reducing demand or raising revenue.

The TUC strongly supports the founding principles of the NHS encapsulated in Clause 4 of the 1946 White Paper which states that “all the service, or any part of it, is to be available to everyone in England and Wales. The Bill imposes no limitations on availability – e.g. limitations based on financial means, age, sex, employment or vocation, area of residence, or insurance qualification.”

Indeed, the TUC believes the range of free entitlements should be expanded through the provision of a unified national health and social care service.

Evidence suggests that the introduction of charges is counter-productive and penalises those with ill-health on lower incomes. The Barker Review points to a lack of rigorous evidence on the impact of charging, but reflects on the RAND study from the USA that found the one notable effect of charging on health service usage was that it had “a serious adverse effect on those who were poor and suffering from poor health”, and therefore the Review concludes that “at a time when concern over inequality is rising, this is a major argument against charging everyone. It would fail the criterion of equity”.[40]

Looking in more detail at the RAND study, researchers at the Health Policy Institute at the University of Texas found that “the deterrent effects of user charges bear more heavily upon those with lower incomes, as this group is more sensitive to increases in price. In fact, low-income persons reduced use of care that was judged by researchers to be highly effective more frequently than did their higher-income counterparts. Low-income individuals at elevated risk benefited most from free care, and low-income people in poor health who received free care experienced the largest reduction in serious symptoms. In conclusion, the greatest beneficiaries of free care were low-income persons with elevated health risks”.[41]

In considering the implementation of charges for clinical services, the Wanless Review stated that “the ethos of the NHS – comprehensive care available to all – commands universal support. Over 90 per cent of people believe that the NHS should be available free of charge when they need it.”[42]

While Wanless acknowledged that the funding of health care through general taxation obscured real costs to patients, the review found that “it is not evident that a greater exposure of patients to the costs involved would necessarily lead them to take more responsibility for their own care … there is no evidence this constrains demand”. Wanless concluded that “it would be inappropriate to extend out-of-pocket payments to clinical services … such charges are inequitable unless accompanied by adequate exemptions and risk increasing inequalities … while they could yield substantial revenues, they would also involve additional administrative costs”[43]

What are the requirements of the future workforce going to be and how can the supply of key groups of healthcare workers such as doctors, nurses and other healthcare professionals and staff, be optimised for the long term needs of the NHS?

There is little doubt that proposals to provide greater integration of services across and within the health and social care system, to boost productivity and innovation and provide tailored services to people with complex and long-term needs, will have significant impact on the health and social care workforce.

In Greater Manchester, where the move to integration is progressing as part of a wider devolution process, the GM Health and Social Care Partnership states that “the imperative to create, at scale, a health and social care workforce which is enabled to work within a ‘place based’ care system, across organisational boundaries will require a shift in the way in which we are developing the workforce for the future.  The GM Strategy provides the health and social care system with a unique opportunity to review and reimagine the type of workforce we require for the future by adopting a parallel approach to educational reform supporting workforce transformation for the current and future workforce, at pace and scale”.[44]

The Greater Manchester workforce strategy paper claims that the scale of change proposed “will impact significantly on ways of working, challenging traditional roles, introducing new relationships, new teams and indeed new professions including the vocationally qualified”.[45]

These changes to roles, relationships and ways of working may arise from plans to, among other things:

•      integrate health and social care
•      shift resources away from hospitals and into community services
•      create single shared services for acute hospital services and specialist services
•      enable standardisation of information management and technology.

While these proposals are specific to the current strategy adopted in the Greater Manchester plan for health and social care, it is reasonable to assume that this reflects thinking across the wider NHS and social care system and will be applied elsewhere.

In addition to meeting the challenges of the future direction of travel, there are a number of existing pressures that need addressing in order to both meet the needs of the current system and help facilitate the changes required to develop the workforce of the future.

In their joint staff-side submission to the NHS Pay Review Body for 2016/17, health unions set out their concerns about “the impact of pay restraint on recruitment and retention, as well as problems with workforce supply and staffing levels.” The unions argued that “these issues will cause lasting damage to the NHS workforce unless they are dealt with through a long-term co-ordinated strategy”[46]

In social care there are also very significant challenges in providing a workforce that is empowered, trained and equipped to deliver the changes required in an integrated health and social care system of the future.

The 1.7m, mainly female, workers in social care are employed across a diverse range of largely private providers, many employed directly through personal budgets and direct payments. Many parts of the sector are characterized by low pay, low skills, under-investment in training and development and high turnover of staff. Much of this results from the flawed commissioning models used by most local authorities, where providers are not given certainty over the number of hours they will be asked to deliver and where cost is usually the determinant factor in the award of contract. These cost constraints, uncertainty and risk are passed on to the care workforce, resulting in a proliferation of zero hours contracts, 15 minute visits and infringements of the National Minimum Wage through unpaid travelling time[47].

In the joint staff-side submission to the NHS Pay Review Body for 2016/17, health unions argued that a workforce strategy for the NHS should address:

•      The impact of wage stagnation on recruitment and retention, morale and motivation
•      Future recruitment, including student commissions
•      Retention of existing staff including consideration of career progression, training opportunities, health and wellbeing
•      Pay and reward of staff delivering NHS services across the UK, across health and social care and those affected by transfer out of the NHS
•      Positive approaches to improve productivity: including better rates for bank and overtime work; implementing the recommendations of the Boorman Review; and investment in staff.[48]

A further set of specific existing issues related to both the health and social care workforce that a workforce strategy would need to address might include:

•      Shortages of clinicians and nurses in order to provide safe staffing levels
•      Workforce shortages in a range of occupations including specialist nurses, middle grade doctors, social workers
•      Demographic pressures in the workforce, including the large numbers of GPs and nurses nearing retirement
•      Recruitment, retention and training of a high quality workforce in the residential and domiciliary care sector – incorporating uplifts to the National Minimum Wage – and creating a commissioning and employment model that is fit for purpose
•      Investment in the quality, development and skills accreditation of support staff, including Health Care Assistants
•      Provision of high quality apprenticeships across health and social care, while delivering the 28,000 starts required in the NHS as part of the public sector apprenticeship levy and target
•      Shifting towards more flexible career options in order to meet the needs of an increasing proportion of women and older workers with caring responsibilities among both clinical, medical and support staff
•      The timescales involved in training new staff, the impact of previous training commissioning decisions and the impact of reforms to training bursaries.

Given both the demands of the future proposals and existing pressure points and challenges across the health and social care workforce, it is imperative, as health unions argue, that we have a joined up workforce strategy that works at a national, regional and local level.

However, workforce planning is a major gap.  Apart from in Scotland where the workforce planning system is centralised and mandatory, the approaches in other parts of the UK are hit and miss.  Service transformation projects related to the Five Year Forward plan for England are varied and diverse.  Trade unions are not routinely involved or engaged and it is difficult to assess the implications for the workforce or potential impact.  In Wales, there are workforce planning structures and a system, but the focus is on maintenance rather than forward thinking and innovation.  There is no joined up workforce planning across the UK.

In the absence of an effective national workforce plan, health unions are planning to set out a draft workforce strategy in their forthcoming staff side response to the Pay Review Body for 2017/18.

Health unions believe that there is a need for a workforce strategy that harnesses the NHS Staff Council refresh of the Agenda for Change pay structure; which is aligned with the initiatives in the national and regional partnership forums on culture, wellbeing and leadership and which engages trade unions in service and workforce transformation.

At the time of writing, it is proposed that a workforce strategy should include the following strategic aims:

•      Changes to the Agenda for Change pay structure that make it simpler to explain, understand and operate; with shorter pay bands, fewer points and no overlaps between bands; that make it fair and affordable for now and the future - achieved through the ongoing NHS Staff Council review of Agenda for Change
•      Maintaining the current NHS Job Evaluation system which delivers equal pay for work of equal value as the basis of Agenda for Change underpinning the pay structure - achieved by NHS Staff Council Leadership, dynamic and interactive training for local evaluation and healthy engagement with the process by local employers and unions
•      Supporting a healthy and safe workplace with high quality employment practices and procedures which promote a good work-life balance, dignity at work, promotion and protection of employees’ health, well-being and safety at work, job design which provides employees with autonomy and control and equitable access to training and learning and development opportunities for all employees - achieved by coordinated and consistent national and local activity in the NHS Staff Council, national partnership forums and employing organisations
•      Safe staffing levels with the right number of skilled professionals in the right settings - achieved by evidence based workforce planning at all levels, national and local and the engagement of the trade unions and professional bodies
•      Promoting the NHS as an attractive place to work and an employer of choice.  Terms and conditions that support good recruitment and retention of staff, motivating staff at all levels and supporting staff development and career progression underpinned by well-structured appraisals - achieved through the ongoing NHS Staff Council review of Agenda for Change
•      Effective change management through engagement with trade unions locally and nationally and sound policies agreed jointly by employers and trade unions - achieved through positive participation on the part of employers, trade unions and the respective departments of health
•      Promotion of quality, diversity and inclusion
•      Promotion of the NHS as a learning organisation – the NHS facilitates the learning of all its members and continuously transforms itself through support for staff development and career progression underpinned by well-structured appraisals at all levels in all employers
•      A focus on leadership at all levels.

Health unions believe that these aims support and reward the improvement of staff productivity and are supportive of the longer term health and social Care agenda and the corresponding workforce needs across all four countries of the UK, and that this will help achieve ongoing improvement in the quality of patient care.

Returning to Greater Manchester, it is therefore encouraging to see that the GM Health and Social Care Partnership workforce strategy paper adopts many of these principles including:

•      CPD Opportunities - All staff to be afforded CPD opportunities as appropriate to individual work role and responsibilities and aligned to new ways of working
•      Equality, Diversity and Inclusion - All staff to be treated with dignity and respect and within an agreed values based culture
•      GM HR/Workforce Strategies - Development of a suite of common HR/Workforce Strategies to support a standardised approach
•      Safe Staffing – to ensure adoption of national strategies on safe staffing levels
•      Joint education and commissioning  arrangements – To work with Universities, employers and providers (HEE, Skills for Care, Further education etc.) to deliver the future health and social care workforce
•      Engagement – to work with trade unions and employer representatives to facilitate integrated working between health and social care unions and management representatives.  Positive and meaningful employee engagement is integral to the successful achievement of GM ambitions and the delivery of the devolution agenda
•      Good Employer practices – to develop a brand for GM as a good place to work through looking after staff well-being, providing good career and personal development opportunities and offering high employment security (dependent on role flexibility).[49]

21 September 2016