Examination of Witnesses (Questions 1
MONDAY 21 OCTOBER 2002
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.
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 trainingit takes three
or four years depending on specialty to fill those gapsat
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
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
(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 numbersand 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 litigationit
seems to be everywhereare 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?
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
(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.
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
(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
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
(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
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.