Speech to the Council of Deans of Health’s Full Council Meeting, Manchester, 16 October 2014
Professor Dame Jessica Corner, Council Chair
I have been asked to start off our meeting by giving a few thoughts as the Council’s new Chair, setting out my stall if you like. I hope you will forgive me exercising this prerogative; I can only do this once.
I want to offer a few reflections. Firstly, on the Council itself, having now seen it from this new vantage point and with my first 100 days as Chair now nearly up. Secondly, what I mean by ‘a new settlement’ and addressing why and how might we set about reshaping the health/HE relationship.
1. The Council of Deans of Health
What foresight the founders of the Council had in investing in such a force to underpin what we do. We must not take this for granted; we must nurture and grow it. And beyond the Council itself we have a powerful network of connections. As our recent Alumni event demonstrated, we have a wealth of history and well-connected friends.
As a membership organisation, comprising 85 HEIs across the whole breadth of the UK, England, Wales, Scotland and Northern Ireland, we encompass the preparation of 30,000 students plus a year. In England we know that this makes up 74% of students commissioned by the NHS. We work across a huge range of professional disciplines, with different working relationship, agreements and practices in each of the four UK nations. We estimate that across our members our combined pre- and post-registration education activity alone totals more than £1.2bn annually.
In all, nursing, midwifery and allied health professional students make up five to six per cent of all students studying at UK universities. There are 58,000 postgraduate students studying subjects allied to medicine according to HESA data, comprising about 11 per cent of postgraduate students studying at UK universities.
And herein, in the size, strength and breadth of our sector, lies a message about our future settlement and how we should develop it and let in unfold.
There are challenges. Only 0.1 per cent of the nursing workforce in England are professors. AUKUH has an aspirational goal of having 1 per cent of nurses, midwives and AHPs working in a clinical academic role by 2030. How are we to achieve this? We know that 83 per cent of health organisations report experiencing qualified nursing workforce shortages. 45 per cent have recruited outside of the UK in the last 12 months to fill nursing vacancies and 55 per cent are looking to increase the number of qualified nurses. We face a pretty acute shortage of nurse, midwife and allied health academics and research leaders, and pension changes in 2016 could trigger a crisis.
Our work covers the whole span of professional preparation, career-long development, postgraduate education, advanced studies and research preparation through MRes and PhD programmes. Much responds directly to the needs of NHS and health and care sectors and is developed in partnership but there is also a strong tradition of education built around University strengths and research programmes. We are also as a sector increasingly powerful in international education as we export our knowledge and expertise around the world, with a growing number of international students in healthcare programmes.
Our Dean leadership community is strong, vibrant and vocal. Among our members and alumni feature world-renowned researchers, not just in nursing, midwifery and the allied health professions but also biomedical science and social science. We have fellows of Academy of Medical Sciences, other national Honours and now the first nurse to lead one of the Medical Royal Colleges. This is an extraordinary resource on which we can draw and around them in member institutions are academics and clinicians with a truly incredible range of expertise. These are the knowledge producers for our disciplines, the NHS and global health care, as well as producing the future workforce. They nurture and guide extraordinary talent, developing the current workforce and playing a critical role in maintaining, indeed raising standards of professional practice and the capabilities of professionals that make up the most substantial part of the health care workforce.
Safe staffing could not have gathered the momentum it has without the crucial evidence from RN4CAST and the NICE evidence review. Who are Molly Case – the student nurse whose performance poem went viral after the RCN Congress last year and William Pooley, nursing Ebola patients in Sierra Leone, if they are not our students and recent graduates?
My six years’ involvement in the Council to date tells me that understanding of and respect for this crucial contribution is often absent amongst the vagaries and pressures of an ever-changing landscape. So I am trying here to let you feel the significance of our community and our joint effort and the confidence we can take from this.
2. My first 100 days as Chair
My first 100 days as Chair are now more or less up. They have told me:
All I had been led to believe about it being quite straightforward to fit in with the day job were purely enticements to those of us considering putting our names forward for election.
What an extraordinary staff team we have. This investment by our University members is a rich and important resource providing much support and sense (if at times some troublesome challenge) for the benefit of the health community in its widest sense. And how good it is to have a wonderful team of Executive Team members in support.
How politicised our work is. Barely a day goes by when we are not responding to a political agenda at some level or in some way across our four home nations. And alongside this, I can see how little understood and at times, perhaps, valued, our work is.
As a flavour, I have already met with Jackie Smith and Mark Addison of the NMC, Madeleine Atkins at HEFCE, Giles Denham at DH, attended a Downing Street reception for nursing and carers, been part of joint negotiation meetings with UUK, DH and HEE over the benchmark price in England and thought carefully with Brian about our response to the Scottish referendum on independence. I look forward to meeting with Welsh Deans in November; to forthcoming meetings with the Royal College of Speech and Language Therapists, the Chartered Society of Physiotherapists and the Allied Health Professions Federations; and to hosting a dinner on the Shape of Caring Review.
3. What do I mean by a new settlement and how might we set about reshaping the health/HE relationship?
Post-Francis and with the Vale of Leven Inquiry Report due imminently in Scotland, we are in a highly politically-charged world, with knee jerk solutions frequently found and forced onto the agenda. Universities, students and how students are trained have been a particularly soft target for ill thought-through solutions to a problem that has not been fully identified. There is also a huge strategic risk of hospital-focused inquiries when most care happens outside hospital and the majority of the NMC register and much of the HCPC register now works outside of the NHS.
All this rests on a historic legacy of deep ambivalence about the value and importance of nursing, midwifery and allied health disciplines, of a stereotyped and largely misogynist view of what is needed and an essentialist view of women and caring roles. Inherent, rather than learnt, this is a view that says that our professions do not require specialist knowledge. It is this narrative that we need to change. Values based recruitment and pre-degree care experience are launched by ministers as top down initiatives with all the hallmarks of these ingrained attitudes; unsurprisingly we feel a deep resistance.
This narrative also runs directly counter to the reality of what is needed to respond to challenges in health and social care. One in four patients in hospital has dementia. The number of people over the age of 85 has more than doubled in the last three decades and will double again by 2027. By 2030, 20 per cent of people will be over the age of 65. The number of people with multiple morbidities is soaring. More than ever, we need our professions to be inventing and working to identify the solutions to the challenges facing the health and care systems.
I recently took part in an ESRC seminar series on social science and nurse education – a collaboration between King’s College London, the Universities of Warwick, Nottingham and Stirling and the RCN. I participated in a seminar looking at the future of nursing leadership and practice post-Francis, with extraordinary inputs from Davina Allen from the University of Cardiff, Graham Martin from the University of Leicester and Ellen Annandale from the University of York. The picture of nursing work that shone through these studies is not reflected in the extant narrative, in the NMC code or in current discussions about selection for values and compassion in practice. This was a picture of nursing in a world dominated by managing an entirely fragmented system of care, both within institutions and between care settings, where nurses act as critical ‘glue’ shaping communication to bridge failing systems driven by managerialist prerogatives (waiting times, productivity models, efficiency, audits and data dashboards). This is not encompassed within a professional code focussed around compassionate interaction with single patients, yet it is a key and ongoing risk.
If that is nursing, then the issues for the allied health professions are rather different. Rather than highly politicised, with quick fix responses, here the problem is relative invisibility. We have a huge challenge to think through how we give voice to the enormous opportunity we have in ensuring recognition of the key contributions that allied health professions can make to the current need to transform health care around care integration, chronic disease and frail and elderly individuals.
I have been privileged to be a member of the 2014 REF panel for Allied health, Dentistry, Nursing and Midwifery and Pharmacy. The results are not yet available and will be public in December. But the extraordinary work of our institutions is very apparent, with real impact and tens of millions flowing through schools and Faculties in research funding, wealth generation and enterprise. A few examples: stroke rehabilitation, quality of life for older people in care homes; reducing the impact of hospital acquired infections; falls prevention programmes; independent prescribing; illness and employment; and cancer.
In this context, what does a new settlement look like? What are its components?
At its heart we need a different relationship, with greater recognition of our work and where we can fully realise our contribution to health and care.
We need to fiercely protect our independence from the NHS. Academia remains an important place for nurturing freedom of thought, knowledge creation, ideas and innovation. This must be protected and strengthened. Equally, we must protect our role in nurturing talented individuals when we can’t predict where or how they will contribute.
This takes us far beyond workforce planning numbers. I was recently at a recent celebration for high achieving students and a group of final year midwives were talking about their plans for launching their careers. These ranged from getting started and consolidating their experience in a local NHS Trust, through to working for Médicins sans Frontières and to seeking out opportunities for research. This is all OK.
In essence, I believe that the new settlement must have four elements:
The first is about changing the transactional relationship between health and universities
In each of our nations this seems to be played out differently. But government funding and direct, hands on ownership of training numbers and price has created a relationship that is fundamentally not about value and contribution, but one of servant and master.
There are opportunities in each of our nations for a new financial settlement, through which we should aim to move away from a direct transactional relationship. We need to ask what the right price is for quality education that prepares nurses, midwives and AHPs for future health care. Given that workforce planning has failed, do we need it? Do we want to move to a more unconstrained education numbers model, based on demand, as in many other countries? How do we build and nurture the academy?
The problems with Benchmark Price and our future negotiations epitomise much of this. We are seeking nothing less than to secure agreement to take forward the design of a new model of funding. The dynamics we design into this will reshape the settlement and our relationship with our paymasters. Indeed on this, we need to ask if our ‘paymasters’ should primarily be the student, a partnership model between government and student, employer and student, or a combination of these. You will be debating this later this afternoon and we need your input.
The second is about standing
We need to make clear what value we add. Can we answer the question: what do we produce? And how we do this collectively? We need a multipronged, national and international effort to build clarity around the ‘value’ we produce (workforce, knowledge, advice to the system, wealth and innovation); collating (as we do for REF) indicators of our esteem: all the ways we can evidence our involvement in knowledge production, advice, consultancy, the myriad committees, advisory and funding bodies we sit on for the NHS, for the academic world, for industry, for charity and NGOs; using the results of REF 2014 to bolster our case. We need to articulate and explain our contribution to wealth and economic growth, putting the case for how we are exporting our expertise for the benefit of global health outcomes.
Medicine and engineering have as their starting point the necessity of these disciplines and their science base as the essential capability and contribution to be protected at all costs, with undergraduate education a key vehicle for sustaining this directly and indirectly. Why don’t we? The Shape of Caring Review holds huge potential to design a new future for nursing and we need to ask how we might achieve the equivalent for midwifery and the allied health professions, looking from a UK perspective.
The third is about our influence
Nurturing and placing this well to deliver the new settlement is a key component and capability we need to further develop.
The fourth is sustainability
We need the right level of funding to enable our work to thrive, to grow our capacity within the sector and to develop resilience to government policy changes and public funding decisions. We urgently need to carry out a bottom up costing review of education, so that we have the evidence base to argue for funding that recognises this, considering the right model of student/employer/government funding mix.
In setting out what I see as the Council’s strength, that is our ability to network and influence and our weight as a body of institutions and individuals past and present and the army of supporters through our graduates and network of relationships, I believe it illustrates that we can achieve a new settlement for the sector. The elements of the new settlement comprise – moving away from a transactional relationship with the health system, achieving a new standing based on recognition of the value we create, using our influence more effectively and achieving sustainability for our sector of which government funding is likely to become a smaller proportion. We now just, and I say ‘just’ as if it is easy, need to consciously get on and do it.