Select Committee on Public Administration Minutes of Evidence

Examination of Witnesses (Questions 1 - 19)




  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.


  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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