Examination of Witnesses (Questions 40
- 59)
THURSDAY 31 OCTOBER 2002
DR IAN
BOGLE AND
MR DAVID
HART OBE
40. How much inefficiency should there be in
the system?
(Dr Bogle) You have to operate at least ten per
cent below bed occupancy to be safe, to free up your A&E
and to allow this freedom of access. It is all dependent on getting
the information we were talking about earlier so that patients
and the professionals they are talking to can make an informed
choice.
41. In my area, all my secondary schools have
the choice, not the parents, because their targets have sent them
in that direction.
(Mr Hart) Absolutely. In London, for instance, the
situation about admissions is chaotic.
42. How do targets reflect that situation?
(Mr Hart) I do not think you can. I am not sure it
is the impact of targets. It is simply that certain schools are
perceived to be more successful than other schools. The schools
which are more popular than other schools, because of their results—we
are talking about simple, good school results—attract more
and more pupils. That does not necessarily lead to greater efficiency
because the appeal panels often overrule the schools; more pupils
come in and they do not necessarily have the staff and certain
classes get bigger and bigger. We have yet to crack the problem
of how you inject additional capital into expanding schools which
are successful. That has a knock on effect for other schools which
are struggling and are perceived to be operating ineffectively
and inefficiently. It certainly has an impact in terms of recruitment
because teachers will tend to move from the less successful schools
and want to teach in the more successful schools. The people who
really suffer at the end of the day are the parents who cannot
get their children into the school of their choice. In London
at the moment, there is quite a lot of evidence of children who
have not got into the schools they should have got into from the
beginning of this term. They are still out of school and we are
beyond half-term just.
Kelvin Hopkins
43. I have some sympathy with teachers and head
teachers. My wife was a teacher for many years so over the breakfast
table I had all these problems on a daily basis. I was also almost
obsessed with the problems of education because probably two thirds
of our young people who were less academic were being failed by
society, by the system somehow. Do you not agree that, without
this vigorous involvement of government in standard setting, testing,
rigour and setting targets, we would not have changed that and
the fact is it is changing now?
(Mr Hart) I have absolutely no doubt about that at
all. The government's intervention since 1997 has had a dramatic
impact. Now the debate is moving and this is where this Committee
session is so important. Michael Barber, the guru now at 10 Downing
Street, said quite categorically that in his view we ought to
be moving from what he readily accepts was a very prescriptive
agenda to informed professionalism. That was the expression he
used. In other words, we must rely on the professionalism of the
teachers led by the heads and informed means with all the data
and information they now have at their disposal, to use that to
best effect. That is why there is talk about autonomy. Yesterday,
Charles Clarke was talking about restoring the trust to the profession.
The time has come for us to try and put some flesh on the bones
of that debate. What does it mean: restoring trust in the profession?
If the government accepts that it had to do what it did in order
to shake up the system, at what stage do we take the foot off
the accelerator pedal and start to move into a situation where
we get the balance right? At the moment, the balance remains wrong.
There is still too much bureaucracy, far too much time and money
spent on driving through these targets in a very prescriptive
way.
Chairman
44. All those teachers who from 1997 onwards
immediately were complaining about this external intervention
were wrong, because it has produced this dramatic improvement.
(Mr Hart) They complained because it did have an enormous
impact upon them in terms of their workload and that is still
being sorted through these discussions and negotiations we are
having with the Department about reforming the workforce, reforming
the teaching profession and reforming the support staff, getting
the work/life balance right. They were right to complain about
the impact it had on their lives, on the hours they were working,
but I think it was inevitable. I do not see how it could have
been done otherwise. The situation in 1997 was not satisfactory.
Something had to be done. The government chose to do it that way.
It has caused pain. We do not want to go into the old OFSTED regime.
That has changed to a certain extent as well now. The whole combination
of the government's drive and the OFSTED regime certainly put
a great deal of pressure and stress on our members and on the
class room teachers. Was it worth it? Obviously, the people who
lost out, who left the profession burnt out and took early retirement
will say no, it was not. That is quite right. For them, it was
not worth it. Was it worth it for the education service? Yes,
I think it was, because we now have got ourselves into a situation
where we ought to be able to build on that, moving through into
secondary schools and beyond. If the government wants to retain
the confidence of the profession and really work, as Charles Clarke
said, in partnership with the profession, led by my own members
who have a key role in terms of delivery of the reform agenda,
we have to get that balance right.
45. I have sympathy with teachers and head teachers.
I think they have made tremendous efforts in recent years but
I want you to suggest to me an alternative to what ordinary teachers
complain about: bureaucracy, paperwork, teachers working until
ten at night, filling in forms, ticking boxes and whatever, that
kind of regime that has bee imposed on them, which they find very
difficult. Is there a practical alternative to that?
(Mr Hart) Yes. It is the outcome of the negotiations
which we are starting next week with the Department in detail,
which we hope to conclude by Christmas—quite ambitious—in
achieving contractual change for the profession and in achieving
a massive increase in the numbers of support staff. We are talking
about 50,000 more support staff between now and the end of this
Parliament; refocusing the role of support staff, bringing in
people to support the heads and the rest of the staff in bursarial
positions, administrative positions, technical support because
of the computer networks etc, and refocusing to a certain extent
the role of class room assistants. All that, if it is brought
to fruition, will I think make a fundamental change. It will not
be from day one; it will be over a phased period of time obviously
for spending reasons, but I think that holds out a real prospect
of a significant difference in the attitude of the teaching profession
to the workload issue. I am optimistic that we have a package
we are just about to negotiate on. The big thing about that is
we have the support staff unions with us. We have UNISON, GMB
and T&GWU working with the teachers' organisations in trying
to get a unified package agreed with government. I think that
is a major plus because for too long the support staff have felt
themselves to be a bit out there. They ought to be with the teachers
in trying to get this answer right.
Sir Sydney Chapman
46. You have graphically explained to us how
local education authorities had to sign up to the targets and
how the schools effectively had to sign up to the targets and
therefore there was very little room for variety in the curriculum.
Does that mean that, for example, schools that have a reputation
for specialising in music, to take one subject, cannot any longer
do so?
(Mr Hart) No, it does not mean that. The OFSTED report
which came out recently demonstrated on the basis of 30-odd schools
that there were and there are schools in the country still delivering
a broad and balanced curriculum, including music, but there is
no doubt that a lot of heads have been driven by the very focused
literacy and numeracy strategies into marginalising areas such
as music and drama and sport. That is generally accepted as being
the reality in a lot of schools. That is going to have to be turned
round. The government has committed itself to make sure that all
primary schools do deliver a broad and balanced curriculum. There
is a major issue about where we find people to teach music, modern
foreign languages or sport or drama, for that matter. That is
part of these negotiations about how we can perhaps get into our
schools people who are not qualified teachers, who have a real
gift for sport or music or languages. There is a lot more willingness
to be open minded about how we deliver these things. If we can
try and persuade 24,000 heads in England and Wales that the agenda
is moving, that autonomy means autonomy, that the expectations
placed upon them to sign up to these highly bureaucratically arrived
at targets is going to be relaxed, without accountability being
relaxed in any way, shape or form to the governing body and the
parents, I think we are onto a winner.
47. Tangential to that, what might or might
not worry some parents is that, if the curriculum is getting into
a straitjacket, a lot of such subjects as, drama and music, might
become extramural activities. I come from Barnet and we have a
pretty fine record on music. They have Saturday morning music
centres. Would you deplore that trend if any school wanted to
specialise in certain subjects outside the core curriculum, that
they would have to have extramural arrangements? Do you think
that would be a bad thing?
(Mr Hart) I think it would be a bad thing if we could
not deliver a broad and balanced curriculum for the vast majority
of schools within the normal timetable week, or within what I
think is going to be a different week. We are going to move into
a much more flexible and longer school day, a longer school week
maybe, as matters develop, in which we can deliver a broad and
balanced curriculum. At the end of the day, what do the parents
want? The parents want a broad and balanced curriculum but if
you ask them what they primarily want it is what you and I want
and that is decent standards of literacy and numeracy. That has
to be the number one priority. We have arrived at a situation
where that is not just the number one priority; but it is not
such a priority that other, very valuable aspects are lost track
of. Performance in the non-academic subjects does have a beneficial
impact on performance in the academic subjects.
48. Dr Bogle, you were pretty scathing about
targets and you explained why. The distortion of clinical need
caused by adherence to the targets or trying to meet the targets:
have you any hard statistics that, for example, to take perhaps
the most worrying factor if it is true, people needing serious
operations are held back in order to undertake the easy, quick
ones to meet targets? Do you have anecdotal evidence or hard facts
on that?
(Dr Bogle) It is mainly anecdotal because for hard
facts we rely on the hospital returns, as the government does.
It is the people actually working in the system. My colleagues
tell me, going back to the example I gave of the simple procedures,
to hit waiting times or waiting list figures, to take on a whole
raft of simpler procedures while you leave the more complicated
still on the list but still underneath the target on the list.
From my personal experience, my practice does endoscopy sessions.
There is a partner who is interested in gastroenterology who,
at pressure times for the targets, is invited to do extra sessions
of endoscopy to get the figures down. Although the procedures
are very important to the patients who are having them, they are
being artificially brought up the list to take the figures down.
We have not an overall picture of the UK.
49. Surely you would be capable of getting that
with direct access to doctors, consultants and so on? Is that
not one of the first priorities your association should have?
(Dr Bogle) I will see if the information I have given
you is right by doing some research when I get back. If we have
that information, you will have it in a memorandum.
Chairman
50. It would be helpful because in the article
you wrote recently you talked about meaningless targets that distort
clinical priorities. We have talked about some of the distortions
and you have given examples of that. I am not sure you have told
us about meaningless targets. I think you signed up to the idea
that these targets were all very splendid, but that they had certain
consequences. If you could put some flesh on some of that for
us, it would be very useful.
(Dr Bogle) I did promise that I would produce more.
The memorandum was obviously without the advantage of all the
other paperwork.
Mr Prentice
51. The consultants have been offered a pretty
good deal, have they not, to help the government deliver on a
whole series of targets? Why have they not accepted the contract
and offer which gives a minimum of 10,000 a year extra, a maximum
of 17,000 a year extra and that is just for NHS work? The consultants
can still go and earn thousands of pounds in the private sector.
(Dr Bogle) I would have to give you the feedback from
roadshows we have done rather than being able to break it down
at the moment. Very many of the consultants did not believe the
arithmetic. You have given figures on earning increases. They
dispute them, from their own experience. That is item one. The
second thing that is reflected in quite a few of the letters I
have received is that, "I am delighted to go in on a Sunday
morning to follow my patients up as my proper, professional obligation
to my patients but I am not willing to sign up to a contract whereby
I can be instructed to do that every Sunday."
52. It is only 40 hours, is it not? We are talking
about an NHS contract of 40 hours and there will be a job plan,
will there not, which will have to be agreed with individual consultants?
(Dr Bogle) Yes, but if it is not agreed the consultants
would have the right of appeal. If that right of appeal was not
in their favour, it would be imposed.
53. The consultants are not going to be dragged
in every Sunday morning, are they? There may be occasions when
consultants as professional people will be expected to do a little
bit extra on a Sunday or on a Saturday morning but ordinarily
consultants will have a pretty big say in their working week.
(Dr Bogle) You and I, without the heat on in this
room, might agree that in theory but when asked to sign up to
a contract where that is a belief rather than a reality I believe
that that is one of the main reasons they have rejected it.
54. Without the new contract, a lot of the targets
that we have been talking about will run into the sand, will not
be delivered. What is the sanction? Do the consultants just work
to rule, to their existing contractors? What happens then?
(Dr Bogle) The targets that are meaningful are as
deliverable under this contract as the new one, I believe. They
are dependent on the ownership by the consultants of the target
and not just the consultants but people working in the health
service. The important thing is that the targets are meaningful
and, in my belief, are focused locally.
55. You want to see the melding of national
targets and local targets. Are consultants team players? Would
they go along with the local consensus or would they operate a
kind of consultants' veto?
(Dr Bogle) Nobody should have a veto. The consultants,
the GPs, the nurses and particularly the patients would have an
input locally into deciding what targets areas were important
in that area and the consultants, like the others, would sign
up to that. What is wrong at the moment is that the targets are
imposed from on high. A lot of them do not appear as relevant
as some other targets that the local people might want. Therefore,
they are not owned. If you do not own a target, you reluctantly
try and hit it.
56. The problem is that there is a lot of scepticism
out there that all this talk of professionalism masks a kind of
self-interest and not a wider public interest. Is that fair?
(Dr Bogle) No, I do not think it is fair. I can understand
the perception. Obviously, if one is thinking about the consultant
vote at all, I know where some people will be coming from what
they believe that means. I have worked with these guys, particularly
the ones who negotiated that contract, so I have heard the debate
about what consultants felt about the contract and I have a lot
of the correspondence from consultants who were not very enamoured.
I believe that they are deeply committed to the health service
like other doctors, but I believe that there are certain things
in that contract that, if you are going to sign up to and sign
up to for your life long work, they perceive as dangerous.
57. The government wants to publish death rates
for individual surgeons from 2004. Do you have a problem with
that?
(Dr Bogle) As long as the statistics hold up to scrutiny
and as long as they are accompanied by the circumstances under
which the consultants work. Take a surgeon. You are going to publish
my death rates. I will be judged by that. If I am down on the
table, maybe you can have sanctions taken against me. I will do
simpler work so that I do not have the mortality rate. That is
the danger.
58. It would not spur you into better performance?
(Dr Bogle) It will spur me into performance in areas
where I know there is a minimum amount of risk.
59. We are told that in a very recent survey
of 40 hospitals looking at coronary bypass operations and so on,
cardiac work, the hospital that came out best with the lowest
death rate was the Bristol Royal Infirmary. Some people suggest
that that is a consequence of the dreadful events at Bristol which
made the surgeons—no pun intended—sharpen up their
practice. Is it not absolutely astonishing that Bristol should
be top of that particular league table?
(Dr Bogle) Yes, I suppose, in view of the history.
It would be totally unfair to try and break down the reasoning.
You implied, because of the performance problems before, they
have made it better. You may be right; I do not know, but the
most important thing that has come out of this is asking for reasons
for performance. Going back to your original question, have I
any problem with mortality rates, if they are accurate, no, but
as long as they are accompanied by the reasons why they might
be off the scale. If the reason is that I am performing an awful
lot of hazardous, highly complex surgical operations with a known
high mortality rate, you have to take that into account before
you publish a bold figure. The one thing that is not happening
in the health service is, before the axe falls, why did you not
reach your target? Are you having a problem? Could we help with
that problem?
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