§ 11.10 p.m.
§ Mr. Kenneth Lewis (Rutland and Stamford)
I am sure the Minister and I are glad that this debate is taking place after a guillotine motion, otherwise we would probably have been discussing the question of agency nurses in the National Health Service at seven o'clock tomorrow morning.
This debate arises out of Circular HSC(II) 164, sent out by the Department of Health and Social Security, of 19th June this year. It seeks to do away with 1457 agency nurses in the NHS. One sub-clause says:Staffing suffers from an additional clement of instability and discontinuity particularly where there are frequent changes of agency nurses and this is liable to affect patient care and staff communications adversely".I do not object to a reduction in the number of agency nurses in the National Health Service, but I do object to any attempt to do away with them altogether. It would have a disastrous effect on the Service. If Ministers were tempted to do away with them, it would not assist stability. It would rock stability, especially, for example, during holiday periods. If there were no agency nurses, more permanent staff would have to be taken on and for most of the year they would be under-employed. That would be a more expensive operation.
Where minimum agency staff are employed, discontinuity does not matter. Permanent staff would already be there in situ and agency staff would be entirely under the control of the permanent staff—matrons, deputy-matrons, sisters, and so on.
The circular also says that agency nurses should not be involved in management because this might be harmful. Of course agency staff should not be involved in management, and they are not. Management is a matter for the nursing hierarchy or the hospital administrators.
The circular goes on to say that the employment of agency nurses has an effect on training. But agency nurses have nothing to do with training in the hospital service. They are not involved. They do not determine what should be done by other staff who are permanently employed. Student nurses are trained by the ward sister or the sister tutor at the school to which they belong.
Again in paragraph 2d. it states that the employment of agency nurses may "mask" manpower problems in the health service. In fact it might highlight the problem. If agency nurses are dropped, extra permanent staff must be recruited. Items 2 f. and g. refer to the cost of agency nurses. This is the nub of the problem for the Minister because his case rests on the argument that agency nurses are disruptive and more expensive. There has been a survey which showed that, bearing in mind the hidden costs of 1458 employing permanent staff, the cost of employing agency nurses is 6 per cent. less than the cost of employing permanent staff.
The self-employed must now pay an additional amount in their national insurance stamp which thus reduces the take-home pay of agency nurses. It is take-home pay to which the Minister refers in advancing his argument. On the other side of the coin, the National Health Service must pay an additional cost in terms of pensions. There is also the cost of sick leave which is built into the service agreement. It must also bear the cost of holidays which permanent staff enjoy as of right, while agency nurses receive no holiday pay. If all these items of the social wage are added to the wage cost figure calculated by the Department, the result is that the level of permanent staff wages goes up towards and beyond that of agency nurses.
The Minister gave figures for the cost of agency nurses in a Written Answer to my hon. Friend the Member for Harrow, West (Mr. Page) on 19th February. He said that the average cost of a permanent nurse in the health service was £3,577 a year and that the cost of an agency nurse was between £3,000 and £4,000; he did not give the exact cost. But the average of those two figures is £3,500 a year, and that means that on the Minister's own figures agency nurses cost less than permanent staff.
In 1973 there were 257,975 nurses employed in the health service in the United Kingdom. In addition 21,146 were employed in midwifery, giving an overall total in excess of 278,000. The number of agency nurses employed was 4,061–2 per cent. of that total. All this fuss is being made over 2 per cent. of nurses employed at a cost no higher than for employing staff nurses, taking into account all the fringe benefits.
Who are the people that the Minister wants to get rid of? They are married women, women who have children and who need to go out to work. They are mothers in single-parent families. They are women who look after parents or children and who have part of their time available. They are trained people who have retired from other jobs but who can make a contribution to the hospital service. They want to do a job, but they 1459 can do it only if they are allowed to work fewer hours and are not forced to go into full-time employment. The service needs them and it is already using them.
The Minister says "Once we do away with the agency nurses, the people who come from outside to work part-time in the National Health Service, we shall recreate the system by providing banks of nurses." That was what the Department's circular said. But that would not achieve any savings. A bank system in the service would have to be run by someone, and it would employ more people running it than the outside agencies employ in running their services, for which the Minister and the hospital service pay nothing. Such a system would also have to bear the cost of advertising for personnel, and the cost of advertising for personnel in the National Health Service is already high. There is no justification for adding to it, and there is no justification for the service having to pay when it is already being paid for by the agencies which provide the people whom the service needs.
The agencies have been registered since 1943. There is no complaint about the standard they provide, no complaint that they are not giving the Minister and the hospitals the kind of expertise that is needed. The agencies have to provide a service which is regulated by certain rules which make it imperative to provide the right kind of service and the right kind of people. I very much doubt whether the health service would have been using them until now if there had been any complaints about their ability or the kind of service they provide.
The truth is that in this, as in so many other matters, the Secretary of State is following and not leading. The right hon. Lady has been pressed by the unions to get rid of agency nurses. Like Lady Godiva, she says "I, too, will display my talent for appealing to popular acclaim." She did that with pay beds, and she is doing it in this matter. If she is not careful she will also, like Lady Godiva, finish up on a monument, as the Minister who destroyed the National Health Service by covering up the real deficiencies through the public display of popular but bogus statistics.
If action is taken on the circular, if the hospitals do what the Minister says they should do, what will be the result? 1460 Beds will close. The service to patients will become worse. Waiting lists will increase. Costs will rise. An already rocky health service will become even more rocky. If the hospitals carry out the terms of the circular, the part that has been played by the outside people who come to work in our hospitals will be seriously diminished. In International Women's Year the Secretary of State will make it more difficult for married women who can work only part-time to play a part in the health service. Is that what she wants?
Unions and administrators in the service are to blame in many cases for people opting for agency work. I was on the management committee of a hospital for 12 years, so I know about these matters. I know someone who wanted to work in the service part-time, and her example can be duplicated throughout the country. She had worked in it full-time, and after her marriage she wanted to continue the same work part-time. She was told, however, that she could not have the same holidays as her husband and could not have the odd day off when necessary. On pressure from the unions, the administrators provided no flexibility to allow her to work within the service permanently and meet her domestic needs. She became a permanent agency employee.
That is not necessary. What is required is additional flexibility built into the service. I make this forecast to the Minister: that in the next year—and he knows it—a great deal less money will be available for the National Health Service, as for other Government services, and hospitals will not be able to recruit up to the numbers of permanent staff allowed by their establishments. Restrictions on the employment of permanent staff, imposed not because men and women are not coming into the service but because of the lack of finance to pay for them, will cause a situation in which, if the Minister also clamps down on the employment of agency nurses, wards will be closed in many hospitals throughout the country.
Wards will be closed on the ploy normally used by management committees. I have served on one and done it. A ward is closed and the reason is said to be redecoration. It is closed for that 1461 reason because it is not wanted to reduce the beddage, which is maintained until the management committee can no longer afford to pay for the nurses to man it.
If agency nurses are to be used only for emergencies—perhaps the Minister will explain what he means by "emergency", which is the term used in the circular—what will happen about filling in for holidays, which are not emergencies but normal events? Are permanent nurses to be employed for this purpose, so that they are kept underemployed for the rest of the year? What is to be done about filling in for sickness periods? Are permanent staff to be employed for that purpose, so keeping them underemployed for the rest of the year? What about filling in for the heavy winter months experienced by every hospital?
If hospitals do not have agency nurses, they will need to employ extra permanents. If they have to do that and if at the same time, because of Treasury finance not being available, the Minister imposes a clamp-down, the hospitals will have to reduce their service to the public. They will have to close more wards. They will have to give an inferior service. They will have to lengthen their waiting lists. Fewer patients will be given the treatment they require.
The circular is ill advised. It poses a political posture. Political postures when dealing with health are never good, and the Minister should seek to withdraw it or hope that it is not implemented.
§ 11.29 p.m.
§ The Under-Secretary for Health and Social Security (Mr. Michael Meacher)
I welcome the opportunity to discuss the use of agency nurses in the National Health Service. Perhaps I should say how pleased I am that the subject has been raised by the hon. Member for Rutland and Stamford (Mr. Lewis), who played a very important rôle in regulating the work of employment agencies generally and who promoted the Employment Agencies Act 1973. He will remember that we supported that when we were in opposition.
I noted that the hon. Member said at the start of his speech that he supported a reduction in the use of agency nurses, though not their elimination, but his comments afterwards scarcely bore out even 1462 his acknowledged belief that there should be some reduction, and I hope that I shall be able to persuade him of its merits.
I do not want to belittle the excellent work that individual agency nurses and nurses' agencies have contributed over recent years. But the problem is that our dependence on them, though it is still very small over the country as a whole, has increased substantially in certain areas of the country, especially in London, over recent years. It was clear to us that the time had come to make some move to halt this development, and I do not think that the hon. Gentleman necessarily disagrees with that.
Perhaps I might illustrate the problem with two or three significant figures. The hon. Gentleman perhaps underestimates the extent of coverage of agency nurses. Whereas in 1965 the number of agency nurses and midwives in English hospitals was only about 1,450 in whole-time equivalents, by April 1974—we have no more recent figures—it had risen to about 4,850. That is rather higher than the figure which the hon. Gentleman mentioned of a little over 4,000. The number of qualified nurses has of course risen over this period, but in percentage terms the number of agency nurses has risen more sharply and they constituted not 2 per cent. as the hon. Gentleman said but 3.6 per cent. of all qualified nurses in April 1974—and the proportion probably has increased since then—compared with 1.5 per cent. 10 years ago. That is a substantial increase.
The real impact of agency nursing has been in London and the South-East, as I am sure the hon. Gentleman realises. One in five of all staff nurses in the Thames region is employed by an agency. In our view, this is quite unacceptable in the interests of good management.
I know that in a number of quarters, particularly the agencies which have nearly trebled in number since 1968, there is a belief that the Government have decided to act for ideological or administrative reasons without real regard to the needs of the service and of the patient. The hon. Gentleman made some play of our paying regard to the attitude of the trade unions. I put it to him, however, that this emphasis is not fair and that what he says simply is not true. There are very real problems associated with 1463 agency nurses, and we set them out in the recent circular to health authorities. The most important is that where agency nurses are employed, especially if there is frequent change, continuity and stability in the working environment for all nurses are affected, and the patients suffer in consequence of the continued change in the nurses who are attending them.
Agency nurses tend to be less willing or able to play a full part in administrative work, and the training and supervision of student and pupil nurses may also suffer, precisely for the reason to which the hon. Gentleman drew attention. It puts the responsibility for these important parts of the work on to the remainder of the nurses, and that is why it breeds considerable resentment. Secondly, the morale of nurses employed by the hospital itself may also be lowered.
For many young people the agency way of life is attractive in giving them the opportunity to choose their own hours and periods of work. But those with a more responsible and caring attitude who are employed by the hospital are naturally from time to time resentful of the apparent privileges of the agency nurses, with their higher take-home pay—I acknowledge the point that the hon. Gentleman made there—and greater freedom. On the subject of higher pay, my right hon. Friend the Chancellor of the Exchequer has made proposals in the Finance (No. 2) Bill which will ensure that in future agency nurses along with other agency employees pay income tax through the PAYE system under Schedule E. We have also advised health authorities that they should not pay more than the Whitley Council rates. We think that these two measures should reduce the disparity, which was in most cases more apparent than real, in the pay of the two types of nurses.
§ Mr. Kenneth Lewis
The hon. Gentleman has just made the extraordinary suggestion that advice has been given to the effect that agencies should not pay more than Whitley rates. On what basis can any Minister tell an agency—people who, after all, are self-employed—what rates they should pay?
§ Mr. Meacher
It is a matter for the health authorities as to the rate they 1464 will pay nurses who are subcontracted to them from agencies. That is the point I am making. That is the advice we have given health authorities.
§ Mr. Patrick Cormack (Staffordshire, South-West)
I should briefly declare an interest. Will these measures take account of holidays, sick pay and the other things, so that they do not penalise the agency nurse?
§ Mr. Meacher
They take account of total employment costs. To that extent there is inevitably built into it some disadvantage for the agency nurse. I should add that the agency nurse will still be exempt from superannuation contributions.
For many years successive Governments have felt the need to reduce the use of agency nurses in the health service. Ten years ago, in 1965, the Department imposed a ceiling at the then current levels of employment on the numbers of agency nurses, but by 1971 the numbers were once again causing anxiety and the Department again advised health boards to review their use and to plan both short-and long-term reductions. I hope the hon Gentleman will accept this substantially bipartisan policy. But as the figures show, far from reducing its dependence on them the NHS has increased its use of them. It was clearly time for us to make another concerted effort with authorities. The recent improvement in nurses' pay, following the recommendations of the committee of inquiry chaired by Lord Halsbury, and the present financial constraints which make efficient use of manpower a prime objective seem also to favour our present efforts.
After consultation with staff as well as management interests, my right hon. Friend issued a circular in June asking health authorities as a matter of urgency to reduce and, where practicable, eliminate the use of agencies and to report to the Department on the targets they have set themselves, the progress being made and any problems encountered, including any effects on services to patients. We have called for these reports by the end of October this year and will take stock then in case any further action is necessary. This is obviously essential if our present effort is not to go the way others have gone.
1465 To achieve the long-term objective of a more stable nursing force of directly employed nurses, with its consequential benefit for patients, my right hon. Friend has explicitly accepted that there could be some risk of a temporary reduction of services in some areas. It will be for local decision how best to proceed with phasing out agency nurses and, of course, authorities will endeavour to eliminate agency nurses to the maximum degree possible without incurring such reductions of services. At the end of the day, however, they may be necessary in certain areas if the long-term benefits are to be reaped. By adopting a restrictive approach on the use of agency nurses we hope to give the necessary stimulus to a number of nurses to give up the agency way of life and return to the NHS.
My right hon. Friend thought it right to show authorities that she accepted that they might have to make hard decisions involving temporary reductions of services, and would support them, but we