Examination of Witnesses (Questions 1
- 19)
THURSDAY 31 OCTOBER 2002
DR IAN
BOGLE AND
MR DAVID
HART OBE
Chairman
1. Could I welcome our witnesses this morning,
Dr Ian Bogle, Chairman of the British Medical Association, and
Mr David Hart of the National Association of Headteachers. It
is very kind of you both to come along. As you know, we are engaged
in an inquiry looking across government at targets, league tables
and associated measurements of imported devices to see what they
are contributing, if anything, to public services and how they
might need to be moved, changed, developed in some way. We look
to you as people who are speaking for major groups of workers
in the public sector and whose lives are dominated in many respects
by this measurement culture. I know that you have both had strong
things to say about it and we want to tap into some of that today.
Who would like to kick off with a few words?
(Mr Hart) I have just a few words as
a supplement to what we said in our memorandum. There are some
pretty key general issues, first, the relationship between central
government regulation, what I call the top-down process, and the
strong belief, certainly amongst our members, that target setting
is an extremely good and useful management tool but that it is
much better if it is a bottom-up process, in other words if you
start with the school and you end up with central government rather
than starting with central government and ending up with the school.
That is an important philosophical issue. Secondly, I welcome
very much what the Secretary of State said yesterday in terms
of autonomy, although I have some difficulty with the expression
"earned autonomy" as opposed to "autonomy",
and respect for the professional judgment of the teaching profession.
I feel that if the Government is going to make that a living reality
they do need to re-visit the way in which the target setting and
the league table process is arrived at. The third point is not
to under-estimate the bureaucracy associated with the whole process,
certainly in terms of schools. It starts obviously with the Treasury
and the Department and the public service agreements and then
moves down into the best value operation at local authority level
and then it moves through the local authorities into some pretty
detailed and intricate negotiations between the local authority
and each and every school in that local authority to see if everybody
can sign up to targets which enable the local authority to sign
off their targets that they negotiate with central government.
When we talk about bureaucracy, and again I welcome very much
what Charles Clarke said yesterday about busting the bureaucracy
and the red tape which does surround us to a certain extent, part
of that bureaucracy is the way in which the whole target setting
and league table process is arrived at.
2. That is very useful as an introduction. Dr
Bogle?
(Dr Bogle) The Government has set a multitude of national
targets in the Health Service but it is the Government's insistence
that these have to be met that is causing the problem. If you
think that there are some 400 targets in the NHS plan and there
have been many that have evolved since then, what they are causing
is a distortion of clinical priorities at patient level, a failure
to use the increased monies being put into the Health Service
effectively, managers having to reach targets at all costs and
at times taking measures that are not acceptable, and an inability
to deliver the Government's stated intention in shifting the balance
of power, moving that power down to primary care trust level with
the input from the professionals and the public at that level.
Fulfilling the targets has led to unacceptable changes in behaviour
based on target achievement, not on improved care for patients.
Just to highlight this, there is the diverting of ambulances to
lower priority cases, the hidden waiting lists, not putting patients
on waiting lists overtly but holding them either at GP level or
somewhere else in the hospital, downgrading the clinical conditions
that have not reached target status, so that if you are unlucky
enough to have a condition that has not got a target attached
then you may find that treatment and care is not funded correctly;
re-designation of trolleys as beds on wheels. In my own area where
I have worked for many years the ophthalmic unit cancelled 19,500
follow-up appointments in a six-month period so that new patients
could be seen to reach the target for new patients being seen.
There is also inappropriate use of extra resources. There are
many other examples. Finally, the Government's aim and ours in
the profession are shared: to support and strengthen the NHS to
give much improved patient care, so be in no doubt about that.
We have a good working relationship with ministers, I believe,
but they are not listening to the consequences of what is happening
in the setting of national targets. Discussions between us are
at a very superficial level where they say to me, "You disagree
with the target", but that is not the point. There are too
many targets and they are, I believe, confusing ministers into
what is happening in the Health Service. This is not just this
Government. I could never understand why Virginia Bottomley knew
more about what was happening in north west medicine than I when
I was working there and why we had a divergence of view about
the waiting lists and the state of the Health Service until I
found out she was getting her information from regular visits
from our regional health authority and she had been told what
she wanted to hear, not actually what was happening. This is not
a problem just for now although it has escalated considerably.
It is far better in my belief for Government to know what is really
happening so that they can put in measures to improve things rather
than there be this divergence of views about how successfully
the service is operating. Finally, you will know of the National
Audit Office report of December 2001 about the way waiting lists
in hospitals were distorted and the code of conduct that followed
for managers, but nevertheless a BBC poll in October this year
showed that still ten per cent of managers were trying to get
round, in a way that is not acceptable, the targets that had been
set them. That is my opening statement. I can offer, if they have
not already come through from BMA House, the result of the consultant
ballot.
3. We are just looking at it as we speak. You
perhaps should be the person who will tell the world about it.
Do you want to say a word about that?
(Dr Bogle) Yes. There was a 74 per cent turnout with,
in England and Wales, a rejection of the new contract by consultants
of two to one, a rejection by the specialist registrars of some
86 per cent; in Scotland a 60/40 consultant vote in favour of
the new contract but the SPR vote, although with a small number
of SPRs, still being 86 per cent against, and in Northern Ireland
a small vote in favour by consultants, a large vote against by
SPRs and I think it is 0.3 rejection if you add the two together.
Those are the ones I can remember. I have not actually brought
the papers with me. That is what your paper should say.
4. You are absolutely spot on. Perhaps we can
start with that as a way of getting into this. Colleagues will
want to press you on aspects of what you are saying but perhaps
we could open it up in this way. Would not a result like that
be greeted with incredulity by the general public who do not understand
why consultants cannot just be team players like everybody else?
(Dr Bogle) I think that is a fair comment and I believe
that in certain parts of the public and the press that will be
the way it will be received. It is my job, with others, to try
and explain why this has happened. I will do so very briefly because
I have been aware of the probable reject for a couple of months;
it is not just a knee-jerk reaction so please bear that in mind.
Certainly the conflict between management in the Health Service
and the professionals as a major issue in the rejection in my
view. It is not the case that the consultants do not wish to be
team players but the consultants wish to retain some autonomy
in the consulting room when they are dealing with clinical matters
and the belief that managers are straying over, partly because
of target setting, into the clinical work that consultants do
with patients and some of the things that are happening here about
the changing priorities being forced on clinical staff because
of targets is an example of them not having the clinical autonomy
that they had. That is one issue that is partly to do with targets
but it is also to do in general with what is perceived as unnecessary
management interference in the doctor/patient relationship and
they wish to retain that. The other issue, which is not really
within this Committee's terms, is that the contract did contain
as a normal working week what most people would certainly not
consider a normal working week—Saturday morning, Sunday
morning and week-night work as a routine paid within the normal
contract. I believe that is also a major issue.
5. I am grateful for that. If we can link this
to the wider discussion that we are having this morning, will
this not just be seen as major producer groups just saying in
relation to the whole business of trying to get information out
about how services work, "Put the patient at the centre of
them, just keep off, do not interfere with us; let us just do
our job in our own way. Do not ask us to be publicly accountable.
Do not ask us to meet targets set by the democratic process. Just
leave us alone."? Is that not the most damaging aspect of
the way in which some professional groups approach the notion
of accountability?
(Dr Bogle) If I believed that was what my consultant
colleagues were saying then of course it would be damaging, but
we are signed up and they are signed up to a system of annual
appraisal and that was negotiated prior to this contract being
discussed, so when annual appraisal for consultants is introduced
they will, when the legislation allows, also be subject to re-validation
in the same way as the rest of us in the profession. They are
accountable through clinical governance for the clinical work
that they do and they are accountable outside to bodies like the
Commission for Health Improvement, so there is accountability.
What I am saying is that the clinical freedom within a consulting
room to do what is best for your patient is what I believe is
at the bottom of this.
6. But what the record shows is that all those
in the list you gave us just now were strenuously opposed by the
profession year in, year out. It took dead babies in Bristol and
dead patients in Manchester before the profession even signed
up to that little list.
(Dr Bogle) I should not come here to disagree with
you totally but I will do on occasion. I believe that is incorrect
and, as I have been involved since the late eighties at the national
level, I will from my personal knowledge know that it is certainly
not true to do with appraisals. As soon as appraisal was discussed
with Government we were totally supportive and helped bring it
in, and appraisal for GPs was something that I discussed from
1993, trying to get the Government to introduce a form of re-validation
for GPs and we were resisted by the then Government on the grounds
of finance, on those two counts certainly, and we have also supported
the introduction of the Commission for Health Improvement and
all the other trappings that go with it.
7. Let us just try this one more time and I
will hand over. It seems to me that patients want to know which
doctors kill you and which cure you, and they want to know which
schools are effective and which schools are ineffective. They
just want to know that as people who use these services. Why on
earth do professional groups have difficulty in having this information
made available, which is done through a democratic process where
a democratically elected government sets these general targets?
(Mr Hart) We do not have any difficulty with the process
in the sense that the information that comes out comes out very
clearly to parents and indeed to everybody else in the community.
It is very clear how schools perform at Key Stages 1, 2, 3, 4,
at GCSE, at A and AS level. There was the hiccup this year over
the publication of course results at A and AS level because of
the fiasco, but generally speaking there is no doubt about it:
the information about how individual schools perform is out there,
it is in the public domain, but primary league tables will be
out in the near future. It is not an issue of whether the public
should have access to the information; of course they should.
They get access to the information. The issue of course is whether
the information accurately reflects how the individual schools
are performing. We are in the middle of quite detailed negotiations
with the Department on what we call value added which simply means
how successful are you at moving the pupil on from one stage to
another so that you more properly record the performance of the
school. That is really the genuine record of how the school is
doing. We have a problem with the Government's adherence to what
we call the crude level 4, level 5, level 6, level whatever it
may be at Key Stages, and of course again the A-C marker of GCSE
and so on. We do need to move pretty rapidly to what we call a
value added approach, and above all—and this is very important
for primary schools—we need to move towards what we call
a point score approach. In other words, the more you keep saying
the benchmark is level 4 at the age of 11 or level 5/6 at the
age of 14, the more you concentrate on that borderline, not necessarily
very good educational practice. The more you talk about level
5, which is a new marker that the Government has put in for 11-year
olds, the more you concentrate again on the 4/5 borderline. It
does not tell you very much about how the children are doing who
are doing very well to get level 3, special needs children, for
instance. Once we can move towards a situation where we have a
profile which reflects the performance right across the ability
range, the more we will have consensus with the Government. Where
we have at the moment argued with the Government, if you like,
or the Department is in its continual adherence to targets which
are based upon the raw level 4/level 5, whatever it may be, and
attached to that are some quite ridiculous notions. For instance,
we have been arguing with the Department for years as to why they
insist on treating absent pupils as if they are present. You may
think that is a remarkable statement to make but they do. Pupils
who are absent and cannot do the tests because they are away on
holiday with the parents or they are ill are still treated as
present. That obviously knocks the score. When the Government
is challenged year after year on that, they say that if they did
not operate that policy then it would encourage headteachers in
effect to cheat and ensure that the pupils who were going to be
bad news when it comes to tests would be absent from the schools
on those vital days. I think that is an insult, quite frankly.
As long as that debate is still going on at that level we will
have this suspicion.
8. That is a very useful and helpful example.
Just to conclude on this, are you both saying that you in principle
are quite happy with targets, league tables, published information
and so on, but you would just like better ones?
(Mr Hart) In a perfect world I think that my organisation
would not want to see league tables but we have to be realistic
and pragmatic. We are not going to get rid of league tables; they
are here to stay, we might as well accept that and get on to try
and negotiate how the league tables can be based upon something
more, let us say, professionally acceptable, and indeed I think
more informative to parents and to consumers. That is the debate
to be had.
(Dr Bogle) I totally support the provision of information
on the performance of units within hospital and, following on
from that, when the information is more substantial than it is
now, on the performance of individuals within those units. They
have not got the information quite as good and solid as we need
it yet. We would not support working from producing a league table
and those figures then come out of that but inevitably, if you
produce those figures, even if the Government or ourselves do
not believe in league tables, league tables will be produced,
so there is an inevitability with it. We are totally supportive
of the patients getting all the information that is available.
Kevin Brennan
9. Would either or both of you be happy to be
described as trade union barons?
(Dr Bogle) I would be unhappy to be so described because
I am not. I must admit it is not something that I had addressed
really. I consider that my role as Chairman of the BMA is to head
up all the BMA activities, one of which is to represent the doctors
who put me there, however, not to the exclusion of the interests
of the Health Service. I did in my introduction talk about our
support for the Health Service and that was quite genuine. Representing
128,000, there will be people who do not share that view, but
the majority certainly share it. In my background from working
in an inner city practice, the Health Service was an absolute
must and still is an absolute must, so I would temper my baron's
role, if you like to put it that way, with always having the interests
of patients there as well. It is a difficult balancing act but
nevertheless that is what I think a professional body, which is
what we are, should be doing.
10. But you were registered as a trade union
under the1974 Act.
(Dr Bogle) Yes, because of the inevitability that
it would eliminate us from certain activities if we had not registered.
(Mr Hart) Not a baron, no; somebody who is responsible
to and accountable to a national council and accountable to 30,000-odd
headteachers and deputy headteachers. You simply cannot operate
in this day and age without operating in a representative format.
In other words, if I say things, do things, publish things which
do not accord with the view of NAHT members I will know within
24 hours that I have said the wrong thing, I have done the wrong
thing, whatever it may be. We are representing leading professionals.
Headteachers are the people that the Government now heavily rely
upon for the delivery of its reform programme. I have no problem
with that. I am not a baron. I am a representative of people who
have a major role to play in the system and if I get it wrong
they will tell me I have got it wrong.
11. I want to explore that a little bit. Is
this concept of a profession and your members in professions really
relevant these days or is it simply now just something to cloak
the naked self-interest that, for example, the consultants who
voted in the ballot today have shown? There was the famous Nye
Bevan quote that he would get the consultants into the NHS by
stuffing their mouths with gold. Is not the truth now, Dr Bogle,
that there is no amount of gold that you can stuff the consultants'
mouths with when they do not want to work weekends in the NHS
because that is when they have their part-time jobs which can
earn them up to a quarter of a million pounds a year?
(Dr Bogle) No. What the consultants want is a change
in the way they live which is in keeping with the year 2002, like
the MPs have just agreed to slightly change their lifestyle and
the way that they operate. This is conjecture because the vote
got to me just half a day before I gave it to you but my belief
would be that to sign on in a contract to Saturday, Sunday and
evenings at the behest of managers and have no control over it
was something they were not prepared to do in a new contractual
arrangement. Going back to professionalism, and one thing I forgot
in answer to your original question, I am actually a member of
the Modernisation Board so that I do try and straddle that fence
and put my money where the Health Service mouth is as well, and
if I found that that was uncomfortable with my trade union role
then I would not have taken it on. I thought long and hard about
it and discussed it with Alan Milburn before I did sign on, so
I do attempt to fulfil what I said to you originally. I know you
have had the article that I did for BMA News and the reason
for that article was that I am coming to the end of my baronetcy
and I want to enter retirement, and I really wanted to think why
was the medical profession so much more disenchanted than when
I went into practice in 1962? I went through the various factors
we normally talk about—workload, bureaucracy and all that
sort of thing, but the big change was the ability to sit down
with a patient like any of you might do and do what is best for
that patient without outside influences that are unreasonable.
National targets that skew what I am doing in the consulting room
I think affect my professionalism. Professionalism is not protectionism.
12. That is interesting and I would like to
bring David Hart in here because there are these claims that the
professionals are special, a special category of people in the
way that they relate to their job and to the service and so on,
and yet you are telling us today that they are not so professional
that they are not prepared on a widespread basis, according to
press reports and you said it in your evidence as well, to cheat
in order to meet the targets that have been set by the Government.
How can you square that with a claim that they are professionals
who have a higher level of integrity or principles or standards
or whatever compared with workers in any other area?
(Mr Hart) You cannot square it and I think we have
to be very clear about the cheating. I have not a clue, quite
frankly, how much cheating is going on. I can only hazard an informed
guess that it is still relatively small.
Chairman
13. Could you do that for us? Could you give
us a guess?
(Mr Hart) My guess is that it is on the increase but
it is still very small in relation to the totality of the number
of schools we are talking about. I would like to say this quite
categorically, that it is totally and utterly unacceptable. It
cannot be condoned. I can understand why it may be taking place;
it does raise issues relating to the target setting agenda. It
is unprofessional, it is gross misconduct; it leads and has led
and will continue to lead to people being sacked. It undermines
the relationship between the school and the parents and is no
help to the pupil, and it is not very good professional conduct
in connection with your secondary school colleagues. You are talking
about cheating at Key Stage II, at 11, for instance. You are in
fact passing on false information to your secondary school colleagues
and that is not in my view good practice, to put it mildly. I
have no truck at all with cheating, absolutely out. It must be
eliminated if it takes place, but I can understand why some people
are driven to that and those cases come across my colleagues'
desks because we look after them as a trade union and we make
representations on their behalf up to and including General Teaching
Council level. It does raise, however, questions about why people
are driven to that. They are driven to that because of this very
overpowering target setting agenda which, as I have explained
in my memorandum, starts with Government moves through the local
authorities who all sign up to their local authority targets and
then they negotiate with the schools to try and force the schools
to sign up to targets that match the local authority's targets,
and if the school refuses to sign up it is marked and it goes
to the Department: "This individual school has refused to
sign up for the targets we want it to sign up to", and there
are all sorts of ways of bringing extreme pressure to bear on
schools to sign up to targets that the schools do not think are
reasonable and when that happens then I think people get very
scared because they can see maybe Ofsted being called in, they
can see themselves being described as a school moving into serious
weakness and special measures. It does not excuse it. I am just
saying that the climate is leading to this sort of highly unprofessional
behaviour.
14. Presumably with consultants they do not
cheat but they can blame on the venal managers any non-achievement
of targets?
(Dr Bogle) I am sure, though I have no evidence, that
there are consultants who cheat, as you put it, for the same reasons
that have just been outlined, to assist with the managers in reaching
the targets. I have no evidence of that but it would be unlikely,
given the number of consultants there are, if that was not a truthful
answer.
15. Could each of you name one example of a
really bad target?
(Mr Hart) Yes, I can name one which in fact the Government
has mercifully abandoned: the reduction of permanent exclusions
by one third was a really bad target.
16. Because of the distorting effects it had?
(Mr Hart) Because it had no rationale and it certainly
did distort.
17. Have you got a current example?
(Mr Hart) I think the reduction in truancy to 10 per
cent is not a bad target but again it is a target plucked out
of the air. Why 10 per cent? Why not 15 per cent or 20 per cent
or 5 per cent? We want to reduce truancy; God alive, we do not
want children to be out there truanting. It is bad for them, it
is bad for their families, but we do need to get some professional
credibility behind some of these targets. It is not so much the
targets. I have no problem with any of the principle of academic
targets, targets to reduce truancy, targets to improve attendance.
It is the percentage figures, it is the lack of proper consultation
and discussion.
18. Dr Bogle?
(Dr Bogle) There was just one sentence in something
you said before which has disappeared and should not have done.
You implied that in being a professional person you had a higher
integrity than others in other jobs. That is not the case.
19. You would not claim that?
(Dr Bogle) No. You should have the highest integrity
in your job when you are operating it and dealing with your patient
but it does not put you on a different plane from other mortals,
as you implied. Waiting lists per se are a lousy target because
they take no note at all of the patient's clinical condition on
that waiting list. The temptation in waiting list figures is to
do the easy work. In a way that gets close to cheating—cheating
clinically. It is not cheating because you are allowed to do it.
You do simple procedures, you do a lot of endoscopies to get the
list through, although the Government, in fairness, have moved
more to waiting times now which is a more sustainable target.
The other one is access to GPs in 48 hours as an overall, blanket,
immoveable target. Given the number of GPs we have got and given
the impossibility of delivering that for everybody who might ring
in misses the point. If I have a pain in my chest I need to see
my GP within the hour. I do not want to muck around for two days.
But if I just want my blood pressure checked, my ears syringed,
okay.
Chairman: That is very helpful indeed. You have
provoked a number of colleagues.
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