Wednesday 27 March 2019 / 4:27 PM Angela Rayner / Apprenticeships / Jonathan Ashworth

Jonathan Ashworth and Angela Rayner write to Matt Hancock calling for national investment, levy reform and a new deal on apprentice pay.

In the letter, released after Ashworth’s to IPPR speech about the NHS workforce earlier today (27 March), Labour’s Shadow Health Secretary and Shadow Education Secretary write that:

  • “National investment is needed as a matter of urgency to pump-prime growth of the apprenticeship route to higher qualifications in the NHS.”
  • The letter also demands that levy funds must be “used to address the staffing crisis in our NHS, while preventing these funds from being diverted outside the NHS to benefit employers from other sectors.”
  • And proposes “A new deal on apprentice pay [that] would minimise damaging pay-led competition between trusts for apprentices; would ensure that apprentices feel properly valued and rewarded; and would widen participation by offering pay rates that staff excluded from traditional study could live on.”


Notes to editors


Full copy of the letter:


Dear Damian

Cc Matt Hancock


We are writing to you to express our concerns with how the government’s apprenticeship model is currently failing the NHS. While we accept the disappointingly low number of apprentices starting in the NHS reflects trends in the wider economy, at the same time the additional process requirements emanating from the rigid nature of the existing apprenticeship levy is impacting the NHS and closing off important routes for recruitment.


Many NHS organisations find they must go through multiple procurement processes to select training providers able to deliver the different types of apprenticeships they may want to use.


The maximum funding bands set for key apprenticeship standards are widely viewed as falling short of the true cost to employers of delivering the apprenticeships in practice. And the NHS is currently so understaffed and over-stretched that it is increasingly difficult for employers to release staff to supervise, train and support apprentices.


There are three actions which government could take now to improve the system:


  1. National investment

National investment is needed as a matter of urgency to pump-prime growth of the apprenticeship route to higher qualifications in the NHS. Unless the apprenticeship offer can be helped to grow at scale, this route will be unable to function as a countervailing force to the workforce challenges of Brexit and the removal of the NHS student bursary.


National investment will help create the volume of starts needed to establish a stable higher level apprenticeship infrastructure in the NHS.


The government should consider new options on funding to support apprentices of all levels, with both direct investment and improved progression leading to greater support for level 5 and degree level apprenticeships where there is a significantly greater requirement for off-the-job training than the standard 20% required in all apprenticeships. Funding should be open to clinical roles as well as non-clinical roles such as IT, finance and HR.


  1. Levy reform

The government needs to recognise that the health service operates differently from big business and needs to adapt the levy system so that it works for the NHS, with cross-department work to produce more flexibility in the way levy funding is pooled in local health economies. The levy system should be reformed to allow for the recycling within the NHS of any expiring levy funds belonging to employers. The Government should consider options for this funding remaining ring-fenced for apprenticeships and other related training, to ensure that it is used to address the staffing crisis in our NHS, while preventing these funds from being diverted outside the NHS to benefit employers from other sectors. It would reassure the public that money they believe is there to fund the NHS remains in the NHS.


  1. A new deal on apprentice pay

Low and variable pay rates have created a two-tier workforce, so there must also be a new deal on apprentice pay that offers transparency and consistency, as well as integration with the wider Agenda for Change system. In this way the NHS could aim to replicate some of the better approaches to apprenticeships elsewhere in the public sector, such as the civil service in which no apprentices are paid outside the sector’s collective bargaining agreement. A new deal on apprentice pay would minimise damaging pay-led competition between trusts for apprentices; would ensure that apprentices feel properly valued and rewarded; and would widen participation by offering pay rates that staff excluded from traditional study could live on. Employers would benefit from a better motivated workforce, more likely to be from the local population and to remain loyal to the employer that invested in them – a genuine “grow your own” initiative.


The overall aim must be to associate the NHS with a gold standard apprenticeship offer and, ultimately, for the NHS to be a place where those that work for it can learn and grow.


We trust you will take these suggestions in the spirit in which they are offered and look forward to your response.



Jonathan Ashworth


Angela Rayner



Jon Ashworth MP, Labour’s Shadow Health Secretary, in his speech to IPPR about the NHS workforce, said:


Good morning and thank you to the IPPR for hosting us.


Can I start by saying what a pleasure it is to share a platform with Mark Britnell whose brilliant new book is a must read for anyone involved in the future of the NHS.


Mark’s reframing of the debate about healthcare workforce around productivity and the impact a well-funded health care system has on economic growth coincides perfectly with Labour’s thinking and commitment to building a high skilled, high investment economy where prosperity and wealth are shared equally.


As study after study has shown, investing in healthcare, and the staff who deliver it, fuels economic growth, raising productivity of the economy more widely through fostering healthier lives and lower absenteeism, reducing inequalities and fostering social cohesion.


It’s why Labour’s vision for the NHS isn’t just one of funding and improved standards of care – absolutely vital though that is – but we also see local health services as anchor employers providing skilled, secure, quality jobs in communities and integral to our mission to tackle health inequalities.


While today I’m focusing on staffing, I believe questions about future configurations of services, for example,  should be subject to a wider and further test about the socio-economic impact proposed service change might have. If the NHS wants to retain its treasured status with the public it needs to fulfil wider responsibilities.


Yet too often the debate about the future of the National Health Service plays out on the right as a debate about whether we can, as a nation, afford to invest in the NHS whereas Mark’s book eloquently persuades us we cannot, as a nation, afford not to invest in our NHS.


So today, as we head into the 9th year of a Conservative government, we see the consequence of that argument where the government has chosen not to invest in the NHS sufficiently.


Standards for patient care, enshrined in the NHS Constitution and which were routinely met with a Labour government, are now effectively abandoned.


We’ve just had the worst performance against the A&E 4 hour access standard since records began. Indeed the standard hasn’t been met since July 2015; the numbers on the waiting list stands at 4.2 million and the standard that 92 per cent of patient should start treatment within 18 weeks of referral has not been met since early 2016; while over 150,000 patients have waited beyond two months for cancer treatment since July 2011.


When not trying to explain the latest twists and turns of Brexit, news bulletins routinely broadcast pictures from overcrowded A&E departments showing distressing pictures of elderly, often confused patients, languishing on trolleys in corridors.


Satisfaction with the NHS – at its highest with a Labour government- has dropped to 53 per cent- the lowest level since 2007.


Patients, front line staff, trade unions and the Labour Party all repeatedly pressured the government to reset the NHS funding settlement.  Following that collective campaigning they eventually gave ground with the Long Term Plan.


When the NHS long term plan was published most people recognised the merit of its aims, but also felt that one of the greatest risks to not just the plan, but the very future of the NHS, was not having the workforce that could work with patients to deliver the care that they need.


Since 2012, because we have such a fragmented NHS system, we’ve had no clear overarching workforce strategy.


Our NHS is currently trying to provide quality services whilst coping with over 100,000 vacancies. That’s 1 in 11 staff simply not being there, including shortages for nearly 40,000 nursing posts, 3,500 midwives, 2,330 consultants and 1,000 ambulance staff. Given the pressures, it’s a remarkable testament to NHS staff that productivity has risen thanks to their commitment and the investment in capital infrastructure in the run up to 2010.


But we can’t keep expecting staff to do more and more with what feels like less and less when faced with building pressures.


At a time of rising multi morbidity, where we live longer often with a variety of complex conditions, whether that’s diabetes, cardio-vascular conditions, COPD – indeed around 14.2 million people in England – nearly a quarter of all adults – have two or more conditions, we know the answer has to be more investment in primary care staff and those staff who will be carrying out greater integrated working.


Yet far from being on track to recruit 5,000 more GPs the government has actually seen a loss of nearly 1800 in recent years, and two out of every five GPs intend to quit in the next five years. While the numbers of district nurses went up slightly over the last year they are still down by almost 40% since 2010, health visitors have fallen by 25% over three years, and school nurse numbers are down by 26%.


Across other sectors we see pressures too undermining the ability to provide quality care.


We know we are facing a growing burden of mental ill health. Yet three out of four children with a diagnosable mental health condition still do not receive the support they need, whilst our research recently revealed almost 1 in 6 young children aged 15 or under are spending more than four hours in A&E when facing a mental health crisis.


Or take cancer care: in 16 years’ time we expect 438,000 people to be diagnosed with cancer every year. That’s 130,000 more than 2015. Cancer Research UK estimates we will need a doubling of the cancer workforce, yet we can’t keep up with what is needed today. For example vacancies for specialist chemotherapy nurses are as high as 15 vacancies per 100 filled roles in some areas. And just last week, the Royal College of Radiologists revealed vacancies for clinical oncology posts are now double what they were in 2013 – with more than half of vacant posts empty for a year or more.


Across the country we’ve seen example after example of how these chronic shortages are hindering the delivery of good quality safe care.


Until the outcry, Churchill Hospital in Oxford was proposing delaying rounds of chemotherapy for patients. Stafford County hospital shut its paediatric A&E unit, with the former president of the Royal College of Paediatrics and Child Health remarking: “There simply aren’t enough doctors to meet the needs of infants, children and young people.” Or Weston General Hospital in Somerset closing its A&E overnight due to a shortage of doctors.


There are many other examples so it’s unsurprising the Kings Fund, Health Foundation and Nuffield Trust have jointly warned workforce challenges “now present a greater threat to health services than the funding challenges’ or the CQC have observed that workforce shortages are having a direct impact on the quality of people’s care or Trust leaders telling us workforce is the most pressing challenge to delivering high-quality health care.


And although Brexit quite obviously exacerbates the problems our NHS and wider social care sector face- for example we now have fewer nurses and health visitors working in the NHS from the EU- it’s simply not sustainable to simply rely on ever more international recruitment.


The reality is we live in an increasingly competitive global market for health care staff. The International Council of Nurses estimates by 2030 we will be short of 9 million nurses globally; India is rapidly expanding its healthcare system yet is short of 4 million healthcare workers including 2.4 million nurses; China needs to recruit 160,000 extra GPs.


What then should be our response and what is the test for the government?


Let’s start by reframing the issue.


The NHS is the most popular institution in British society.


Yet in the words of the Baroness Dido Harding who chair NHS Improvement and is leading the workforce review “The single biggest problem in the NHS at the moment is that we don’t have enough people wanting to work in it”


This is what is odd.


People love the NHS. But apparently, they don’t love it enough to work in it. They love it enough to give it more taxes. They love it enough – Brexit chaos aside- to make it their number one political priority over most of the recent decades.


At moments of supreme family anxiety, they trust it enough to hand their loved ones to the people that they don’t know who work in the NHS in the knowledge that the kindness of strangers will mean they are looked after


The public love the NHS for all these reasons, but apparently not enough people love it enough to want to work in it.


This is more than a paradox.


It’s a political and social disaster and needs a political solution.


And in developing Labour’s solution to this disaster I don’t want to start where most planning starts, with training and manpower analysis, I want to start with why, even given the loved status of this institution, not enough people want to work in it.


Of course we need to train more – last year there were over 20,000 applications to UK medical schools but only 6,500 places available, so we would match the government’s pledges to expand training places and a Labour government will work with our HE institutions and trusts to look at how we expand training places further.


But if those studying get their qualifications and end up not wanting to work in the NHS, training these extra people is certainly good work for the universities, but does nothing for NHS patients.


To make Baroness Harding’s point in statistics, we have today revealed that over 200,000 nurses have left the NHS since 2010/11, alongside a 55% increase in voluntary resignations from the NHS.


Voluntary resignations citing poor work-life balance have increased by 169% since 2011, whilst resignations for reasons of health have doubled.


So the obvious point behind her quote is that even when they are qualified, people don’t have to work in the NHS if they don’t want to. Wanting to work in the NHS is the key determinant.


There can’t be another job where the people you are serving are so grateful and say it so often.  One of the universal experiences of working in the NHS is the amazing feedback that patients and relatives give to the staff looking after them. Every day, all the time.


Bless you nurse, thank you for your time and thoughtfulness, thanks for the care, is a constant soundtrack to the work of a nurse.  It’s quite moving to witness it.


This must – and does- have an impact on job satisfaction.


But this leads to a further underlining of Baroness Harding’s point. If people experience this strong life affirming patient feedback still don’t want to work in the NHS- something is very badly wrong.


Despite all of this experience of being valued by patients, in too many places staff do not feel valued by their organisations.


Let’s be clear about this. Without solving this problem, without persuading people who today, do not want to work in the NHS, that they should want to work in the NHS, the NHS long term plan simply doesn’t matter.


That means changing the culture of the NHS in how it treats its staff and it means investing properly in its staff.


And it means shifting the national debate amongst policy makers, away from considering extra investment in staff as yet another demand upon the exchequer, but instead understanding that the health and wellbeing of staff, alongside real investment in professional and career development, will not only improve quality of care, but will also drive productivity gains across the NHS. Both of which will hugely benefit the economy as a whole.


As I say, this is Labour’s vision. Not just a well-funded National Health Service, providing the best quality of care, but the NHS as a real anchor institution in our economy, contributing to economic growth and shared prosperity.


That vision begins with fair pay.


I was very proud to announce Labour’s policy in the 2017 general election to scrap the public sector pay cap – I believe it was one of our strongest and most compelling policies.


And because of the pressure we put on the government in the aftermath of the 2017 election, minsters were forced to offer staff a new pay deal.


So Labour is committed to ongoing investment in pay and reward that goes beyond merely breaking the pay cap.


But I believe we have to go further.


It’s worth recalling the NHS Constitution the last Labour government under Gordon Brown introduced, enshrining the rights that staff should expect.


But many of those principles and rights are increasingly being neglected and ignored. For example, the right to:


  • have a good working environment with flexible working opportunities, consistent with the needs of patients and with the way that people live their lives;
  • have healthy and safe working conditions and an environment free from harassment, bullying or violence;
  • be treated fairly, equally and free from discrimination.


It’s my pledge as Health and Social Care Secretary in the next Labour government that those rights and pledges in the NHS Constitution will be upheld.


As Secretary of State it will be my responsibility working with staff and their workplace unions to deliver on those constitutional promises.


In the last 12 months it’s been a tremendous privilege to spend time quietly shadowing frontline NHS staff: from paramedics, to GPs, hospital catering staff, junior doctors, health visitors, mental health nurses, anaesthetists and consultants.


Their compassion and professionalism is astounding. But I also can’t help feeling their goodwill is too often exploited and staff are taken for granted. Whether its inflexible working, pressures so relentless staff feel they can’t take a toilet break or stop for a bite to eat, to inadequate rest facilities or just tiny things like insisting staff provide own teabags, that actually would make a massive difference.



We have to change the culture of the NHS and I want to begin a dialogue about how we do that. No one, for example, should feel bullied or harassed in the workplace. We don’t need to rehearse the figures – year after year, NHS staff survey after staff survey, shows an unacceptable prevalence of bullying and harassment.


When not confronted and left to fester it become toxic.


Not only does this cost the NHS, with some estimating bullying costs the NHS £2 billion, but nor is it good for patient care either with teams working less effectively and higher absenteeism.


Changing the culture of our NHS is key to improving outcomes for patient care.


Indeed as Professor Michael West’s research has shown, one of the strongest predictors of patient mortality rates is where staff work closely together in effective structured teams. In Professor West says ‘good training, learning and development opportunities for staff and support from immediate managers are linked to lower patient mortality rates. It is particularly noteworthy that lower mortality occurs in those trusts whose staff have opportunities to influence and contribute to improvements at work’


It’s another reason why we believe it’s important that staff are properly represented on governing boards of hospitals and health providers.


Staff wellbeing will be a priority and we’ll put in place a national wellbeing strategy with access to occupational health services and practitioner psychological treatment support. We will ensure the creation of board-level NHS Workforce Wellbeing Guardians in every local, regional and national NHS organisation.


We believe it was a huge mistake to suspend the NICE work on safe staffing ratios. An overworked, exhausted workforce corrodes staff wellbeing and patient care suffers. I can confirm a Labour government will therefore legislate for safe-staffing levels too.


And safe care can’t be delivered by tired, exhausted fatigued staff so I’m endorsing the Royal College of Anaesthetists and BMA’s fatigue charter and committing the next Labour government to rolling out a fatigue education programme, helping trusts provide adequate rest facilities as we shift cultural attitudes towards rest in hospitals.


We know the Junior Doctor contract states employers are supposed to provide appropriate rest facilities but often it’s our junior doctors who, following the debacle over the contract, suffer from especially low morale. A recurring and quite legitimate complaint is over the way rotation patterns impact family life.


I was very struck and appalled when shadowing a junior doctor for a day in the midlands when she explained to me how her and her husband – also a junior doctor – had never spent a Christmas day together with their five year old son.


Surely in 21st century Britain we can do better than this? Well at Brighton and Sussex Trust, A&E consultant Rob Galloway, who I have also had the privilege of shadowing on the frontline, has done just that. In Brighton the team developed an innovative annualised self e-rostering system that has seen shifts covered without the need for locums and quality of care improve saving the trust money too. In five years they went from seven consultants and seven registrars to 21 consultants and 25 registrars with consultant cover that is now 24/7. This is exactly the kind of innovation we would want to see rolled out.


And just as I want to put staff wellbeing front and centre, I want to prioritise development too.


I thought the King’s Fund, Nuffield Trust and Health Foundation put it most aptly when they said last week: “The health service cannot afford the Government continuing to view education and training as an overhead cost to be minimised.”


I agree.


Those trusts that have allocated resource to staff development have seen the benefits. I recently visited New Cross Hospital, part of Wolverhampton Trust. In 2016, the Trust was faced with mounting vacancies amongst its junior doctors and growing reliance on very expensive agency staff of uncertain clinical reliability. It set about an imaginative recruitment campaign aimed at recruiting junior doctors by investing in the quality of its posts and in their training done in partnership with the University of Wolverhampton.


This Clinical Fellowship Programme has allowed the Trust to expand this grade of doctors from 65 in 2016 to 150 currently. There is now a waiting list of those wishing to take up a post at the hospital and the Trust has expanded this to the recruitment of nurses, and this too is off to a flying start with 40 nurses recruited since September 2018.


But despite such welcome innovations, the reality has been a continued lack of investment in continuing professional development for the NHS staff more broadly.


The central investment in ongoing training and development for existing staff is now a third of its 2014/15 value, with £84 million dedicated to workforce development in 2018/19 having dropped from five per cent of health spending 12 years ago to three per cent today.


It’s meant non-mandatory training has seen a decline. Last year just 70.9 per cent of staff received non-mandatory training, learning or development- the worst score in the past 4 years. This is despite widespread consensus across unions and employers that CPD is vital to both the recruitment and retention of staff, and to ensure that patients are treated by an increasingly skilled workforce.


And investing in development must mean developing the whole workforce. Staff up to band 4 make up around 40 per cent of the NHS workforce, and are estimated to be responsible for 60 per cent of direct patient contacts yet receive only 5 per cent of whole training budget.


Technological advance and the digital environment will continue to change society and the delivery of healthcare over the coming years.


Additive manufacturing, automation, AI, the internet of things and robotics bring huge possibilities and, as Mark says in his book, will take over many healthcare tasks though not necessarily whole jobs.


But there will be an obvious impact, more likely on those doing administrative jobs. We will ensure therefore that lower banded staff receive extra training and support for the new patterns of working that automation and technological advance brings.


And we will continue to oppose the move to ‘wholly owned subsidiary companies’ – staff should be kept in-house and part of the public NHS family.


So I can announce Labour in government would restore Continuing Professional Development Budgets to 2013/14 levels- a new investment of £250 million bringing the workforce development budget up to just over £330 million. Today we’re demanding government follow our lead and make the same commitment otherwise they risk undermining the final proposals from Dido Harding’s final report.


And because we know years of cuts to capital budgets have left staff struggling to cope with ageing equipment or crumbling buildings, we would invest more in the capital infrastructure of the NHS – in our 2017 manifesto we promised £10 billion extra. Not only would this allow us to invest in equipment and modern technology, but would also allow us to invest in staff facilities to improve the working environment.


Just as we need to do more to retain staff in the NHS we need to do more to recruit for the future too. For too long the supply of new staff has not kept pace with rising demands for services.


The UK trains comparatively few nurses compared with many other countries: in 2014, there were 27 nursing graduates per 100,000 population in the UK compared with almost 50 per 100,000 population on average across OECD countries.

Yet 2018 was the second year in a row in which the number of applications and acceptances for pre-registration nursing degrees in England fell. Unquestionably the Government’s ill-sighted decision to scrap the nursing bursary has been a significant cause. HEE’s own research found that finances are ‘by far the most significant concern for students in all years of study and the number one factor cited by students for the high drop-out rate during training.’


A Labour Government will re-introduce bursaries and reinstate funding for health related degrees so that people who want to get into health professions – whether they are young people starting out or older students who want a new career after starting a family – don’t feel put off by financial considerations.


We are short of 40,000 nurses and we know increasing the nurse workforce is key to improving quality of care and driving productivity gains across the NHS.


So there is a real urgency in fixing this problem.


Yet it strikes me that one of the reasons we have a structural shortage of nurses in the UK is that we fail to make the offer of a nursing career to the more than half the population that do not get good enough A levels to enter a degree. The demand from the rest of the population is not in doubt. When the first 1,000 nursing associates were announced 8,000 staff from the NHS applied for the posts.


We need to develop different routes into getting the nursing qualification which involves opportunities for prospective nurses taking FE courses and distance learning to get into nurse qualification courses.


Given the size of the nursing shortage we cannot throw away the aspiration of so many people because they didn’t, at the age of 18, get A levels.


The government’s failure to fully get nurse degree apprenticeships off the ground has been highly frustrating. Structural issues with the apprenticeship levy model currently make it too expensive for trusts to use properly. For apprenticeships to become a thriving route into the NHS, the Government should consider options for this funding remaining ring-fenced for apprenticeships and other related training, to ensure that it is used to address the staffing crisis in our NHS, while preventing these funds from being diverted outside the NHS to benefit employers from other sectors. It would reassure the public that money they believe is there to fund the NHS remains in the NHS.


Today Angela Rayner and I have written to the Education and Health Secretaries making this point and calling for reform.


I also want us to do more to inspire the next generation of health care professionals too. Increasingly, applications to university undergraduate courses in medicine, health sciences, dentistry and nursing require evidence of an interest in healthcare career prior to application. It can put many off and blocks opportunities. So Labour in government will work with trusts, GP networks, area care footprints to create a schools’ work experience bureau service to inspire and encourage the next generation of health care professional.


Finally, a point on international recruitment.


I’m proud that through its 71 years, people have come from across the globe to work in our National Health Service.


Fourteen per cent of UK nurses and twenty eight per cent of doctors were trained internationally – many from the EU.


They make a vital contribution towards delivering NHS services – they are highly skilled, valued members of our NHS team, and yet the Government has failed to make them feel welcome throughout the Brexit negotiations.


The recently published immigration white paper was also a cause of concern for many, particularly the proposed £30,000 salary threshold required to obtain a visa after Brexit. The fact that the Government seriously went out to consultation with a proposal that would mean that the NHS would collapse is a worrying example of their political priorities.


Too often the recruitment of international staff has been frustrated by a cumbersome unsympathetic immigration regime.


We will therefore ensure work visas to anyone who has a job offer in the NHS, at whatever level and to provide more opportunities we will expand the Medical Training Initiative also.


For Labour, healthcare and the staff who deliver it are national assets to be invested in. Healthcare already represents 9.8% of GDP and investing in and expanding the workforce is not just about the delivery of quality care – the timely treatment for surgery or when presenting at A&E or the ongoing care that our age of increasingly non-communicable disease demands – but is central to our priorities to drive productivity and foster a high growth, high investment economy.


It requires investment in skills, training, infrastructure, technology, leadership and our social care sector too.


The NHS is nothing without its staff, and to be proud of the NHS is to be proud of its staff who deliver valued care every day.


But it is not enough to be proud of NHS staff.


There is a compact, a social contract between our society and those that care for us.


We and our loved ones benefit from a dedicated caring workforce who are passionate about the NHS.


In return, staff should be treated fairly, respected and valued in their work, and feel that their careers are rewarding and their own health is not impacted.


That compact has sadly broken down.


The result of this, as we have explored today, are massive vacancies with subsequent poor performance, high stress levels, decimated training and development and too often cultures born from the high stress environment that our NHS workforce find themselves in.


Through the measures I’ve outlined today, and more, Labour in government will fix this broken compact and address the causes of this avoidable workforce crisis that is impacting too many of our fellow citizens.


By returning to the idea of healthcare as a social and economic investment and healthcare staff as a huge part of this investment, we will return the NHS back to where it should be, as a national treasure to be proud of that everyone wants to work for.


This is Labour’s promise and this is the test for the government in the coming weeks.