Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 1 - 19)




  1. Colleagues, can I welcome you to this session on our expenditure inquiry and particularly welcome our witnesses. I think it appropriate to extend our thanks to you for all the effort that has gone on with the Department in response to our questions. We do recognise that it causes a great deal of work and we appreciate the efforts made inside the Department. Could I ask you to introduce yourselves briefly to the Committee. We are familiar with one or two of you.

  (Ms Edwards) Margaret Edwards, Director of Access and Choice at the Department of Health.
  (Mr Douglas) Richard Douglas, Director of Finance, Department of Health.
  (Mr Denham) Giles Denham, Head of Policy for Children and Older People and Social Care at the Department of Health.
  (Mr McKeon) Andy McKeon, Director of Policy and Planning, Department of Health.
  (Mr Foster) Andrew Foster, Director of Human Resources, Department of Health.

Mr Amess

  2. We all know that we could not run the Health Service without the consultants and I think there is general concern about the training of consultants and the low morale at the moment. I think by 2008 it is projected that there will be over 34,000, which is 10,000 more than the baseline in 2001. I am advised there are only 13,000 employed in the Registrar Group in 2001 so how confident are you that the projected figure will be met? It just does not seem to make sense to me.
  (Mr Foster) The principal route for expanding the consultant medical workforce in the long run is by expanding the number of people going through medical school, recognising the fact that it does take quite a considerable amount of time from the date they first go in as undergraduates to joining the consultant medical workforce. We are taking a series of other steps to expand the consultant medical workforce. We are trying to stem the rate of outflows by offering attractive and flexible packages where people can either partially retire and come back or continue to work part time. We are trying to increase recruitment from overseas. There are two particular schemes there. We are also trying to accelerate the historic conversion ratio from specialist registrars to consultants. Those are the three principal methods of expanding the consultant medical task force and put together we do indeed believe that we can meet those projections set out there.

  3. If the contract is rejected what sort of impact do you think there will be on those numbers?
  (Mr Foster) The immediate impact of consultants on the numbers would be two-fold: one is that we are assuming some extra consultant productivity arising from the contract, so we would need to find further ways of generating that activity by other means. No decisions have as yet been taken on what those other means would be. The other issue on rejection of the contract is that, inevitably, it would lead to some period of depression of morale and we are urgently considering the ways, if that should happen, that we should breach the rift that has somewhat opened up with the controversy over coverage of the contract.

  4. Is it possible for you to say now within the various disciplines of consultants whether one area is going particularly well? Are there shortages in particular areas about which we perhaps need to be concerned?
  (Mr Foster) Yes, medical workforce planning is always extremely difficult because of the length of the medical training, but of course at any one time we find that there are shortages more in one area than another, but because of the length of time it takes to go through the higher training—it takes three or four years depending on specialty to fill those gaps—at any one time, in answer to that question, there will be particular shortages in some areas and particular abundances in other areas and we try to adjust the numbers every year to match up gaps and excesses.

  5. You have provided the projected number of consultants by September 2002 as 27,500, which is equivalent to a headcount increase of 2,431 in a six-month period from the March 2002 figures of 25,074. Can you confirm and report progress of this projection?
  (Mr Foster) I cannot give you detailed progress yet. There was a medical workforce stocktake that took place at the end of September but the figures from that will not be available until early December.

  6. What about the previous period?
  (Mr Foster) I think those figures were the basis of the 2001 figures. They have been reported.

  7. There is clearly a shortage of doctors, of which we are all aware, and the Wanless Report has outlined a number of strategies to address all that. For example, it is suggested that it would be compensated for by the recruitment of health care assistants to substitute for nurses who in turn would be freed up to substitute for doctors. What are your plans for dealing with the doctor shortfall identified by Wanless?
  (Mr Foster) A mixture, including an expansion in their own numbers—and I have to point to what is currently the highest ever number of consultants there has been and each of these subsequent years raises that number even higher, but we do acknowledge that we need medical capacity. Beyond that the strategies described in the Wanless Report are precisely those we are pursuing, so we are finding ways of releasing more direct clinical care from consultants by, where suitable, transferring elements of their workload to other members of the clinical team. There may be roles which can be taken on by nurses or by physiotherapists, but there is also the potential to extend the role of, for example, medical secretaries to carry out a significant amount of the administrative work currently carried out by consultants, thus releasing more of their time for clinical matters.

  8. Given the present tendency for litigation—it seems to be everywhere—are you confident that the different alternatives to doctor support are going to give the patients the confidence that we would all hope we would have in someone who is looking after our needs?
  (Mr Foster) Clearly colleagues working on litigation and the appropriate protocols may be able to add to this, but what I can tell you from the patient point of view is that where alternatives are provided, for example, to GPs or to consultants in the form of other members of the workforce team and the patients are given the choice, then the evidence is that they are perfectly happy to accept other members of the team.

  Mr Amess: Final question, I just wondered if you would like to comment on this: the Royal College—

  Chairman: Which Royal College?

Mr Amess

  9. The Royal College of Surgeons predicts a shortfall of 1,500 by 2010. How is it that they are predicting this shortfall and you are telling the Committee something else?
  (Mr Foster) The methodology of calculating the workforce necessary will vary according to one's particular needs, and I am assuming that the Royal College of Surgeons will have made some particular assumptions about expansion in numbers of patients, about transfer from inpatient to day case and, indeed, about the ability to transfer surgical roles to other members of the clinical team, that might be less ambitious than some of our plans. What I would say in response to that report is we have agreed that there should be the capacity to increase the number of surgical SPRs by 300 this year, subject to the trusts being prepared to take them within their own individual workforce planning assignments, so we have moved towards the Royal College of Surgeons to try and help out on their projections.

  10. So you are in dialogue with them and it is a worry what they have to say and it is a worry that you are acting on?
  (Mr Foster) As I say, all stakeholders will press on you their version of the future. We are certainly very keen to build up the capacity even quicker if we possibly can, so we can meet and exceed, for example, waiting list targets before time, thus we are very sympathetic to any possibilities that can increase the surgical role—

  11. The reason I say that is Department of Health officials are not working with consultants, they are not chatting to them about what morale is like, what is going on, "Are you going to shut up and go overseas?" I imagine the Royal College of Surgeons is very much talking to the people who are performing and carrying out for our patients at the moment. That is why I wondered if the Department was a little bit concerned.
  (Mr Foster) I have to tell you I spend an enormous amount of my time talking to consultants and, in particular, the Department earlier on this year had a meeting with 600 consultants which concluded that we should establish something called the "Doctors Forum", which is not formally part of the BMA consultation process or the Royal Colleges but is a selection of front-line consultants and members from other organisations to discuss precisely those issues of morale, workforce planning, and what we can do to improve those, and some of the work that has come out of that about flexible retirement and return is a result of the dialogue with those consultants anyway.

Dr Naysmith

  12. You talked a little bit earlier on about medical training and training schools. There is evidence coming from a number of European countries that they can train consultants to do the kind of things our consultants do in a considerably shorter timespan than happens in this country. Firstly, is that true? Secondly, if it is, are there any discussions going on with medical trainers to see if we can shorten the training period for our consultants?
  (Mr Foster) It is true that different European countries have shorter post-graduate medical training regimes than in some cases we do. I would say generally where that is the case, the posts that are being created are not directly comparable to the posts we create here. We tend to create fairly generalist consultant posts, so that for example a consultant position will have a specialty of cardiologist or haematology, or whatever, but the consultant will also be capable of working generally across all of the conditions that they receive so they can cross cover. Many other European countries do not operate in exactly the same way. Nonetheless, we are looking at opportunities to reduce the length of specialist and undergraduate training. In some instances schools and colleges are already offering shorter courses in this country. There was some publicity recently for St George's Medical School which is offering a course which has been reduced by one year to reflect the maturity of graduate entrants and there are similar huge expansions of medical students taking place in East Anglia and the West Country which are looking at ways, again, of having four year undergraduate courses rather than five, so there are experiments taking place in those areas and the Chief Medical Officer recently launched a document called Unfinished Business which takes a look at the entire continuum of training and again signposts that we think this is worthy of further exploration.


  13. The last time you were here my recollection is that it was the day you announced progress on the consultant contracts.
  (Mr Foster) I remember well. There is something symbolic about being back here today!

  14. We celebrated of course that great achievement at the time. What was very interesting was my colleague the Secretary of State was talking about a possible ten per cent increase in commitment to the NHS overall. Was that correct at the time?
  (Mr Foster) I think the particular calculation that he was talking about was in relation to surgeons who would be expected to have the same number of clinical commitments they have at present but the unit of currency would change from a three and a half hour session to a four hour session. That was what he was talking about.

  15. The overall 10 per cent was mentioned, as I recall it.
  (Mr Foster) Was it not a higher figure than that reflecting that?

  16. It was certainly at least 10 per cent.
  (Mr Foster) I think it was 14 per cent.

  17. It was a significant increase in productivity. If the current situation in terms of dialogue over the contract means that that may not now come about what assumptions are you making as to the alternative strategies in relation to recruitment to make up for what would be a significant shortfall in the ability to cover in the NHS?
  (Mr Foster) We are certainly beginning to look at alternatives. I have to say no decisions have been taken at this stage. When we were last here we were feeling quite pleased. I did not really think I would be sitting here four and a half months later, with a lot of expectation from various quarters that the ballot might not be successful. As some of the coverage has become clear that there is a high chance of that we have begun to look at alternatives, however it is too soon to give you an answer at this stage.

  18. We will get on to the concordat issue in a few moments. If the consultants are not working an additional amount of time in the NHS, as we anticipated as a consequence of the provisional agreement earlier in the year, what impact will that have on their activity in the private sector and possibly in the private sector undertaking work for the concordat? Have you made any estimate of that? Do you understand the point I am making?
  (Mr Foster) We have thought about this. The ballot is still taking place and there will be media coverage of what is said here so I would rather not be drawn on that for the time being.

  Chairman: Okay.

Sandra Gidley

  19. Can I move to comparative health spending levels, we asked the question you answered in the memorandum as to how the definition which was included within health care spending has changed since 2000. We received the answer that based on some work by the Office of National Statistics health expenditure by charities and religious organisations have been added and R&D, education and training have been subtracted. Can you tell me whether that has meant that the figures now look better or worse as an increase or decrease when you adjust the figures in that way?
  (Mr Douglas) You have a small increase overall of about 0.05 per cent. The net effect is to add an additional £1.3 billion and its impact is 0.05 per cent of GDP.

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