Examination of Witnesses (Questions 140-159)
WEDNESDAY 4 APRIL 2001
SIR JOHN BOURN, KCB, MR GLENN HULL, MR NIGEL CRISP AND SIR BRIAN FENDER
Mr Leigh
140. I have long been an admirer of the health service in France and Germany and the way because they base their funding on insurance schemes that they release a higher proportion of national wealth into health care. Can you tell us a bit about comparisons with France and Germany in terms of nurse training, retention, pay, number of nurses per head of population?
(Mr Crisp) No, I am afraid I do not know.
141. I find that an incredible answer. After all, France is not very far away and we are talking about what is probably one of most important issues in national life. Sooner or later we are all going to be at the tender mercies of the NHS in a very vulnerable state. I would have thought it would have been a priority for you to learn from our European partners.
(Mr Crisp) Firstly, we do learn from our European partners and indeed from people further away.
142. Why did you tell me a moment ago that you had no information?
(Mr Crisp) I could not tell you. If you would like me to find that information I will provide it to the Committee but it is not something that I had briefed myself on before arriving here today.
143. Despite the fact that you have not briefed yourself you cannot tell us anything about it? There is nothing lurking in the back of your mind about it which might interest this Committee? After all, you are the Permanent Secretary and presumably you think about these things occasionally.
(Mr Crisp) No, I do not think there is anything that it would be sensible for me to attempt to speculate about. It seems to me I need to give you answers that are accurate and thought about. I am very happy to do that and I will do it through reporting to your Clerk. I do note that I did not brief myself about it because there was nothing in the NAO Report about it and it was not a point brought out by Sir John or his colleagues.
(Sir Brian Fender) I can give you a crumb of comfort in very general terms about the completion rates in Britain in higher education as compared with France. They are much better; Britain is 82 per cent and France is 51 per cent.
144. Is there a reason for that do you think?
(Sir Brian Fender) We do things better! It is also interesting there are quite big cultural differences between us. We rather pride ourselves on looking after our students, giving them a lot of student support and having this good completion rate. I think you can follow from that that we are being more efficient. I do not know of course but I would infer that the chances are strong that we are being more efficient in producing qualified nurses than elsewhere.
145. I will pass on. Attrition: we are told that the rates of attrition are comparable to rates in further education but of course we are talking about a far more valuable national resource. After all, if somebody gives up studying sociology at a further education college that is a gain for society as a whole while if we lose a nurse that is something very serious indeed. What more can you do in terms of selection, early instruction, guidance into future career to ensure that you have a better rate than colleges of further education? After all, we are talking about a vocational job here and presumably people are more motivated when they start and have a clearer idea of what they are doing. So many people go into, say, a sociology course in further education who not know what they want to do with their lives but presumably people coming to you do have a fair idea. I am surprised, therefore, that your rates are not a lot better.
(Mr Crisp) Let me make two points. The first one is that our revision of nurse education which started coming into place two years ago (and which comes into place fully by this autumn) allows people to step on and off courses much more easily. If we are thinking particularly about mature students this is more likely to be attractive to them. Thus people will be able to come in and do a year and take a break and come back into training and people whom we might have lost in a system whereby you have got to do three years in one shot we are able to retain. The other point I would make, which I think again is a strong one, is we as the employer need to start making the relationship with the students very early on, and that is why there is a new mechanism which I think is referred to here whereby students have a host trust and the trust is asked to start to take an interest in them, to look after them as well and get some kind of relationship with them at the same time as the university is doing that. So I think there is a range of things and those would be two of them.
146. You have talked quite a lot about family-friendly employment. I think this is terribly important. We are talking mainly about women of child-bearing age; it is very important to them. How much training, help, advice is there right through the process even at an early stage so that you can talk people through this and say, "Don't worry, we realise that you are almost certainly going to want to have children and get married and all the rest of it. We can help you through this. We can cut your hours right down, increase them", so that you get career guidance and help right the way through for women so that they can stay in nursing and keep their qualifications up to scratch but look after their families properly?
(Mr Crisp) I absolutely agree that it is extremely important. One of the things we have got is a programme which we are calling "Improving Working Lives" and within it we are accrediting trusts for the way in which they work with their employees and that includes whether or not they have got the sort of schemes you are talking about, whether or not they have got day care facilities, whether they have got facilities for part-time work, whether they have got facilities for career breaks, and so on. We have quite a substantial check-list of the sort of things we believe a good employer should be providing and it does include precisely the approach you are talking about making a relationship with people who hopefully you will be able to bring back into employment after periods of leaving to have a baby or whatever.
147. Do you think that you can both do the job well and provide an attractive job for people with young children?
(Mr Crisp) I think so. I do not know how many of our staff have young children but I think the evidence is that we can do that. There is a big expansion in child care facilities and a big expansion in part-time working and there is evidence that that is attracting people back.
148. Many other professions are breaking down the barriers between officers and men and ensuring that there is much more of a seamless transition from the lower to the high ranks as it were. I am not of course an expert like you but there still seems to be a great barrier between nurses and doctors. Would not the whole profession be far more attractive and would it not be easier to retain people if you made even more progress than you are making in telling people how they can progress up the tree and become doctors having started as nurses?
(Mr Crisp) I am sure you are right that we could do more of that but there are a number of things that are happening like the fact that a significant number of the new student courses for doctors that we are introducing are aimed at people who have already done training of a different sort, so we are attempting to open out the entry gate to that—Sir Brian is more familiar with that—and trying to give more opportunities. The point you make also applies to bringing non-qualified people into nursing. We have a cadet nursing scheme precisely designed to try and bring people into the process and I think over time it will work like that. The other point that is worth just drawing out is we have introduced nurse consultants and nurses and I have to say those nurse consultants are highly respected by the doctors they are working with and I think they are also role models for other nurses who see that you do not have to become a doctor to occupy a position of great seniority and great prestige.
(Sir Brian Fender) We have just allocated in partnership with the Department of Health 1,000 extra entrant places for the training of doctors and a feature of virtually all those universities submitting was that they were concerned about multi-professional training and appropriately providing education for nurses and others mixed with doctors, and a significant number of the submissions made to us were pointed at allowing nurses in professions allied to medicine to progress to doctors.
149. Thank you. Talking about the comparison between nurses and doctors, I was talking to a lady in the last week or two who was suffering from a debilitative disease called lupus disease and she was singing the praises of the specialist lupus nurses. There are very few in the whole country, but apparently the lupus nurse in Leeds General Infirmary is now going to be laid off. They say they cannot afford her and apparently central agencies are not prepared to step in. The lady I was talking to said that as far as the treatment of her disease is concerned the specialist nurse, because she specialises, is far more use than a junior doctor who is a generalist. I know I have not given you warning of this particular instance but it seems alarming. Is this a pointer to what is happening elsewhere in the country because I would have thought these specialist nurses are very valuable indeed and we should not have one of them laid off. We have only a handful of lupus nurses in the whole of the country.
(Mr Crisp) I am surprised at what you say because the trend is precisely in the other direction—to have more specialist nurses in more areas precisely because they are specialist and able to work with the people involved. If you wanted to give me the details I could provide a better answer.
150. Sir Brian, do you know why this might have happened? Can you tell us something not about this particular case but your hopes in trying to train up more specialist nurses and increase their value to the NHS?
(Sir Brian Fender) I cannot deal with this individual case, of course, but I would entirely concur with Mr Crisp that the trend in education is indeed to make sure people have opportunities to specialise.
151. A last question. If you were setting a nought to ten scale in terms of attracting nurses to the profession and keeping them, how high up would pay come in that scale? Is it of overwhelming importance so that everything else pales into insignificance? We hear so much about this in public debate but is pay the overwhelming consideration for recruitment and retention that it is made out to be?
(Mr Crisp) I do not believe it is the overwhelming issue. When you have a service with the number of people we have there are a lot of individual reasons but certainly I do not think that is the overwhelming reason. I think the evidence we have of people coming back into nursing was about flexibility, some of the things we talked about earlier, about the opportunity to make a contribution and to do so in a way that fits in with the rest of their life. I think that is a significant issue for a lot of people. Pay will be a significant issue for another lot of people. It is the whole range and the better we become as an employer the better able we will be able to keep people.
152. You think that creating a flexible working environment throughout a nurse's career is possibly as important as pay?
(Mr Crisp) I do not know that I can make that judgment for 300,000 people. I think they need to make that judgment, not me, but the evidence that we have of the people returning is that it was not pay that came—
153. It was the demands of the job? It interfered with the way they wanted to run their lives?
(Mr Crisp) It was about a trend which is much wider than the NHS of people wanting to be able to work and to have a full and proper life. Certainly the evidence that people have produced in terms of when we question nurses about what it is they are looking for from their job shows that pay is relatively low on their list.
Mr Leigh: Thank you.
Chairman: Mr David Rendel?
Mr Rendel
154. Perhaps I could start as the husband of a GP by assuring my colleague Mr Leigh that any doctor worth their salt recognises that there are many things that nurses do better than doctors just as there are some things that doctors do better than nurses, and the two are not incompatible. Can I clarify one or two things with you, Mr Crisp. I misunderstood somewhere along the line some of the figures you have been giving us. You seemed earlier on to give us a figure about one region, you said that was all you had at the time and that was less than 100.
(Mr Crisp) I think the number was 270. The figure that I have got here which is the country as a whole—and I said that I thought it equated up to 1,500 or 2,000 and the multiplication was obviously wrong—is 4,181.
155. That is in the last year?
(Mr Crisp) Yes, and indeed the number, if you went to February 1999, is 7,000, so it is 7,000 in the last two years.
156. Thank you for that. And the increase in the number of nurses, I think you said, between September of last year and September of the year before the number of nurses in employment was up by 6,000.
(Mr Crisp) 6,200[14]
157. Paragraph 2.25 then on page 22 shows that the vacancies had gone up by some 3,000 in the year up to March 2000. Is that right?
(Mr Crisp) Yes.
158. So the vacancies went up in the year to March 2000 but the number employed went up by double that amount in the year to September 2000. Does that mean that suddenly the numbers shot back up again between and March and September 2000 or how else do these numbers compare?
(Mr Crisp) There are three figures here. There is the number of jobs available, and that went up, there is the number of nurses which went up, and there is the gap between them, which got bigger; it is a moving target.
159. You say it is because the number of jobs is increasing. Is that number of jobs continuing to increase?
(Mr Crisp) I am sure it is, but I do not have a figure that is more detailed than that and our calculations done in the last summer were that in order to meet the demand of the additional jobs we believed we needed for the service we needed 20,000 more nurses, so the calculations do add up like that.
14 Note by Witness: The number of nurses in employment increased by 6,300, not 6,200. Back
