Examination of Witnesses (Questions 1-19)
WEDNESDAY 4 APRIL 2001
SIR JOHN BOURN, KCB, MR GLENN HULL, MR NIGEL CRISP AND SIR BRIAN FENDER
Chairman
1. Today the Committee of Public Accounts will be taking evidence on the Comptroller and Auditor General's report on educating and training the future health professional workforce for England. We have with us Mr Nigel Crisp, the Permanent Secretary at the Department of Health—your second appearance before us I believe, Mr Crisp—and Sir Brian Fender, Chief Executive of the Higher Education Funding Council for England. Welcome again, Sir Brian. You are both familiar with the routine now so I will go straight into the first question and it is to you Mr Crisp. We are all aware of the impact of staff shortages on patients. How confident are you that the education and training arrangements discussed in the C&AG's Report will meet NHS demand for nurses and other health professionals, in terms both of numbers and of quality?
(Mr Crisp) I think my first point is reasonably confident and getting more confident. That is the very short answer. The reason for that is that we have calculated what we need to have in terms of additional training places over the next three years and the evidence of the first year (where we are just completing the plans at the moment) is that we are on target for that, so we have got a good starting point into the period and this is a very big increase.
2. It is only a planned increase as well. Let me pick up on one example so you can go through it perhaps. Case example 2 on page 20 shows that there were only 159 radiography recruits for 197 places. Attrition from those courses, I understand, averages 27 per cent. Given that how confident can you be that you can meet the increased demand for these staff identified in the NHS Cancer Plan?
(Mr Crisp) What I was going on to say in terms of the first bit is there are some areas where we are less confident. If we take the nursing one, we have seen for example that there has been an 87 per cent increase in people applying for courses, so a very big increase over the past few years. You have picked on one of the areas that we are much more worried about which is the radiotherapy one. There is indeed an example somewhere in the report which talks about how we are handling that. We need to target areas such as therapeutic radiographers and we need to be looking at how we can get more people both to start on courses and to stay on courses. The sort of things we have done around radiography include running with the Society of Radiographers a big awareness campaign. We have done a lot work with schools and, indeed, in February we sent out a joint letter on behalf of ourselves and the Society to all lapsed members on the register and I understand there are 14,000 radiographers across the United Kingdom who are not currently in practice, so there are a lot of people we are targeting. There is a lot of work focusing on an important but relatively small number of staff.
3. What are the other areas then where you have concerns of risk? You said you are comfortable with nurses but in what areas are you less comfortable?
(Mr Crisp) You have picked on the one that we are least confident of but the other areas—
4. That was lucky!
(Mr Crisp) Where we need to do more work is in midwifery in particular. That is probably the big one. If you look at the difference between the increases we have had in nursing staff coming through and the change in midwifery staff, you can see we need to do more to attract more people into midwifery and to keep them there. That will be the big area that we are working on.
5. Others I am quite sure will take any and all of those items. Let me move on to Sir Brian and to paragraph 8 in the C&AG's Report. Many universities and colleges appear to be reaching full capacity now according to that paragraph. How confident are you that the higher education sector can accommodate the growth in the required number of trainees to provide sufficient quality teaching and clinical placements, at the same time as meeting other challenges such as widening participation?
(Sir Brian Fender) I am confident. Of course the number of nursing staff and nursing students and others has increased very markedly over the last few years. I have every belief that universities can cope with a further expansion but there are probably two difficulties which we need to be aware of, one there may be some capital needs which need to be taken account of—teaching accommodation needs for the bigger expansion—and we have got to make sure that the salaries of lecturers in nursing are competitive so that we can recruit the appropriate lecturing staff.
6. I will flag that up as two bids for money.
(Sir Brian Fender) You will never find me missing an opportunity!
7. I did not think I would, Sir Brian. Let me move on because others are going to pursue that, I am sure, and paragraph 2.38 is my next port of call. That shows that attrition for NHS courses is broadly similar to that for other higher education programmes. The National Health Service has now set the universities searching targets to reduce attrition to 13 per cent for nurses and 10 per cent for others. How realistic are those targets, and what needs to happen to achieve them?
(Sir Brian Fender) First of all, the completion rates are good here for nursing. You have to take into account, if you like, the background of students when working out what is a reasonable attrition rate, as it is called in the report. There are several factors but they boil down to three important ones, the first is what qualifications the students had on entry, the second is their age, and the third is the subjects they studied. There are variations in all these but if you took nurses and took into account the average level of qualifications of nurses and the average age of nurses then in fact the record here is very good. That is not to say we should not try to make it better, and of course that is our aim. I did want you to be fully clear that in one way of looking at the figures, which I say is deficient because it does not take account of cost differences, the attrition rate may be only half that which you would expect if you were to compare nursing with the sector as a whole.
8. One of the things which struck me here was that you have attrition rate targets for many subjects outside the area we are looking at today.
(Sir Brian Fender) Yes.
9. They tend to be pretty much tailored by courses and institutions and these are very much across the board. Obviously some institutions will hit these target easily and others will find them near impossible. Would it not have been better to have tailored them more?
(Sir Brian Fender) That is what we do with the national statistics. We produce a benchmark which relates the actual attrition rate that an institution has to the expected attrition rate taking account of their particular mix of students. Yes, it is right, we have not been able yet to go to that level of detail of doing benchmarks for individual subjects and institutions. We would hope to do that over time but it is a rather more complex system than you think.
10. It will take some time. All right. Mr Crisp, let me come back to you. I want to talk about figures 8a and 8b on pages 30 and 31 in the report. They show a very wide variation in the price paid per student by the National Health Service for the same professional qualifications. This suggests a wide range of costing and pricing practices and one has to say a lack of transparency. What are you doing to ensure that you get value for money for the prices you pay?
(Mr Crisp) Firstly, in terms of the variations themselves, actually, as indeed the report says, a very large number are actually within quite a tight band and are relatively easily explained in terms of the fact that it costs more in some parts of the country than elsewhere. There are some entirely legitimate reasons for that. The second thing is that in looking at these sorts of tables you want to target the outliers and find out what is actually going on in those cases. Having done that, in the particular ones that are here, it is clear that the very far outliers are very peculiar cases where we have actually got set up costs in for example.
11. That explains the £10,000 one, does it?
(Mr Crisp) That explains the extraordinarily large difference on the left hand table I think. At the other end of the table we have actually got some relatively older contracts where we have had students added on to them at a marginal cost. I think that is the reason why those are relatively lower. In terms of the process, as you are aware, this has come about through a contracting process. What we are doing, first of all we issued some guidance about how you should contract and secondly, and more recently, we are working with HEFC looking at—
12. With who?
(Mr Crisp) With the Higher Education Funding Council, I beg your pardon.
13. We hate acronyms.
(Mr Crisp) I am glad I managed to get it right, at least I hope I did?
(Sir Brian Fender) Yes.
(Mr Crisp) We are looking with them at whether or not we should be benchmarking. Then, having identified some benchmarks, then to look at what are legitimate variations. I think the other point that is worth making though, and again the report makes it, is that over the period that we have been doing this, which is, what, now four years, is it not, we have seen a reduction in costs to the NHS of £7 million. We have seen also in that period a considerable reduction in the variation as well, we are getting towards the norm.
14. Sir Brian, from your point of view, how far do these variations reflect wider deficiencies in university costing mechanisms and to what extent do they reflect other bad practices, poor management, cross-subsidy?
(Sir Brian Fender) There seem to be two questions there.
15. I am sure you can deal with them.
(Sir Brian Fender) First of all, the variations, I think we can easily identify some of the major factors. For example, what capital provision has been made; when the Colleges of Nursing came into higher education what was the state of the buildings that they were occupying. The whole area of capital is one. Pension provisions vary from one institution to another because some universities are a part of the USS scheme, some are part of the teachers' pension scheme, that is one difference. There are clearly differences in location in terms of the costs associated with salaries and travel and so on. Then there is an element here of the judgment by institutions, remember this is a customer contractual relation in terms of the amount of risk that should be carried by the institution and that by the National Health Service. Now, in a way you have three alternatives I think to deal with the pricing of these contracts. One is the customer contractor relationship which is where this began, another is benchmarking the costs, trying to come to a sensible view about what a typical cost should be and then looking for some local variations and, thirdly, you could have an open book examination of the costs. Those are three different ways of looking at the way these costs are arrived at. There is a group set up to look at the whole question of these contracts to find out what would be the optimum way of arranging for these costs to be met. It would include things like the length of contracts as well as the specific method of identifying the cost or price.
16. Some of these figures clearly must either be a marginal cost or even a subsidised basis, some of the lower end ones, and that cannot be very good for the running of your institutions, can it?
(Sir Brian Fender) As Mr Crisp said, these prices have been narrowing. We have looked at some of these low costs and it is clear that on re-negotiation they have tended to go up. There are reasons why institutions might offer relatively low costs, apart from the issues that I have mentioned. They may deliberately, if you like, be looking for this business because it reinforces other parts of their programme and I would consider that perfectly legitimate if they could strengthen the whole programme of the university or college by cross-subsidising. I do not consider that necessarily a bad practice if the overall benefit to the institution is good and the quality of the programme is maintained.
Chairman: I have seen businesses going bankrupt following that logic. Mr Burns.
Mr Burns
17. Can I have it straight in my mind and just check with you. It would be fair to say that a nursing course would cost roughly £5,000 a year so that would be about £15,000 for the whole course, three years. What guarantees do you see, if any, that individuals going through these courses will then, for some point of their career or at some time in their career, work in the NHS so the NHS gets benefit from basically an education that has been provided for by the state? The tuition fees are paid for in a way that they are not for many other courses for students in England?
(Sir Brian Fender) Mr Crisp should answer this.
(Mr Crisp) I do not think we do have a guarantee but during the period that they are in training they are obviously linked to NHS institutions. Indeed, there is a new arrangement whereby students are specifically linked to a host trust precisely to try and build up the sort of relationship which will actually lead to encouraging people to go on in to work within the organisation. Indeed, in a number of trusts now, the subject of this report, people—I am thinking here of nurses again actually—have a supplementary post registration training which is actually provided by the trusts so the trusts are wooing them, if I can put it like that.
18. What checks are done on potential students before they embark on their courses that they are suitable candidates for the course?
(Mr Crisp) I am not sure if I should not pass that one to you, Sir Brian.
(Sir Brian Fender) I think you should. I think there are a whole range of methods that are used, including interview, where it is appropriate. Certainly in my experience of institutions and nursing programmes they take a lot of trouble to make sure that they do match nurse students to the course.
19. Can you then explain something to me in my role as a constituency MP. Why is it that in the last 14 months I have had two people come and see me as the MP for the area asking me to get their deportation orders reversed who are on these courses and one who has asked to come and see me to see if they can get their visa that has expired extended to remain in this country?
(Sir Brian Fender) Groping for a third place, it should be the Home Office representative here.
