THURSDAY 31 OCTOBER 2002
Tony Wright, in the Chair
Memoranda submitted by British Medical Association and
by The National Association of Headteachers
EXAMINATION OF WITNESSES
DR IAN BOGLE, Chairman, British Medical Association, and MR DAVID HART OBE, General Secretary, National Association of Headteachers, examined.
(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 happen to and 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.
(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.
(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.
(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.
(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.
(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.
(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 I, II, III, IV, 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.
(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.
(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.
(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.
(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.
(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.
(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.
(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.
(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.
(Mr Hart) Because it had no rationale and it certainly did distort.
(Mr Hart) I think the reduction in truancy to ten per cent is not a bad target but again it is a target plucked out of the air. Why ten per cent? Why not 15 per cent or 20 per cent or five 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.
(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.
(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.
Sir Sydney Chapman
(Dr Bogle) Yes, that is right.
(Mr Hart) It has certainly shaken up the relationship. Whether it is cosy or not I do not know.
(Mr Hart) It has certainly shaken up relationships to the extent where headteachers now view local authority inspectors or advisers whose prime responsibility is for monitoring standards and for coming into schools doing the negotiations in a different light. They do not regard them as being quite the adviser, the supportive friend maybe, that they used to. Whether that is good or bad I am not sure. I think the local authorities have a job to do. It is one of their five or so strategic responsibilities that they are going to have under the new funding system, to continue to monitor standards. Let me give you a quick example of why I think we have these tensions. Key Stage II 11-year olds: take Southampton as an example. In 2001 in Southampton 11-year olds achieved about 63 per cent level 4 and above in English and 66 per cent in maths. The targets for 2004 - and that is only about three years of tests, by the way - jumped to 85 per cent in Southampton in English and 85 per cent in maths. That is a massive increase in achievement being expected of Southampton. It is that sort of major increase in performance which is expected of individual local authorities that will bear down on our members in Southampton and will lead to a bad relationship I guess becoming more tense and more strained in the years to come.
(Mr Hart) The Department of Education and Skills civil servants will arrive at that target and will discuss that target with the local education authority. The local authority is under a great deal of pressure to sign up. There is only one local education authority in the whole country that refused to sign up to its targets and that was Cornwall. Cornwall refused point blank to sign up to its targets because it said the whole process was completely flawed, and I congratulate the Chief Education Officer for Cornwall for standing out, unlike his colleagues who I think should have been much tougher in their discussions with the local authorities about whether these targets that are being expected of them are really realistic. Each Chief Education Officer has to go through a negotiating procedure with regional offices of the Department plus the central Department in London and, after a very tortuous process, pretty well all of them bar one signed up in the end. Having done that, they then go to the schools and say, "This is what we have signed up with the Department. We have got to get you to sign up to targets so that each school, when put together as a totality, meets the target we have reached with the Department". That is the process. Involved in that process, I said in my memorandum, is a degree of coercion that includes monetary incentives being offered or monetary penalties being suggested if they do not sign up, and in the case of some local education authorities of course they have been threatened with Ofsted if they do not sign up. That is the negative aspect of the target setting agenda which I think is in dire need of reform.
(Mr Hart) I agree.
(Dr Bogle) Like you, I believe in decisions being taken at as local a level as possible. All I would flag up before I specifically answer your question is that when you do that there will be a variation in the provision of service across the UK because there will be different priorities in different areas. That is inevitable. One of the consequences of having that local determination is that there will be variation. The variation will be aimed at the needs of the people, if it is done properly, in the particular area, so I can live with that variation. What I would like to see, and I think one of the most difficult questions is the one that was asked before, - pick a target and explain why it is bad, because individually, when you pick a target, a lot of them seem to be very good until you look at the unforeseen consequences of implementing that target without any further discussion - is the Government cutting down the number of targets that it is putting forward. I think the Government, in the position it has now, has every right to suggest target areas and to set targets, but there are too many. Then I think that locally, through primary care trusts, they should take note of those targets, they should form their own plan in discussion with the public in a local area and the professionals working in that area and produce a business plan for that area that incorporates the Government targets and the local targets and makes it clear which targets they find are the more important for their area. They will need then to submit that to the specialist health authorities so that there is some co-ordination, but then to explain in their annual reports, where they fail to hit targets, why they failed to hit targets and why they gave priority, for example, to other targets that did not appear to be the main Government targets. To give you an example from my past in Liverpool, where smoking related diseases, particularly chest diseases and chest mortality, were, certainly when I was there, the highest in the UK. Smoking is one of the very important Government initiatives but it does not figure as an absolute target and I would have thought in Liverpool they would want to target that above all for the illnesses that they see and so I would expect the business plan to say, "This is why we do it. These are the figures on which we base our targets", and then to argue the case, if they cannot hit them because of staffing shortages or whatever, and there is then some flexibility to debate how a primary care trust can be helped to get back on track and to hit the targets. At the moment it is, "There are the targets. You have got to hit them. No matter how it is, I just want to hear you have hit them". That does not help the patient at all. It can be worked locally. I believe we have the structures in place. It does bring with it some of its own difficulties but I think we have to live with those.
(Mr Hart) Yes, I think there. I think the problem is that the by-products of the target setting process are such that it is difficult to see some heads (not all; they vary enormously, as you well know) using the autonomy/opportunity to be innovative to best effect. We know perfectly well that it has distorted the curriculum, certainly in the primary schools. We are losing music, drama, sport and so on because of the relentless emphasis on literacy and numeracy and yet this is one of the major achievements of this Government, to improve literacy and numeracy levels in the primary sector. It distorts to the extent where I am now getting reports of primary schools having already started revision now, in the autumn term, for next summer's maths and English tests. That must distort the curriculum in most schools. I would like to see schools freed up to be able to develop their autonomy, their innovation, to demonstrate what the Government wants them to have but a lot still feel very constrained by the relentless emphasis on the test results that come out in the summer and the league tables that follow those results, and there is the conflict which we need to resolve in sensible discussions with the Government. I respect the Government's democratic right, by the way, to have targets. I respect its right to have public service agreements. It goes to the country on a manifesto that says education is a top priority. It wants to be judged at the next election in part on achievements in education; I respect that. I just wish that the dialogue was more open and that the Government listened more to the responses it gets from the people representing the profession about the realism of some of these targets and how they are driven down at school level.
(Mr Hart) You certainly do not need it. The question is whether the Department will let it get away with that since each local authority has to file its education development plan with the Department and each local authority has an EDP which is supported by all the targets which the individual schools have signed up to, at seven and 11 and at 14. The DfES has this whole raft of information given to it and I suspect that if a local authority kicks over the traces and says, "Sorry; that ain't our priority in our EDP", they would be smartly told by the Department, "Go away and re-think it. It is not acceptable to us".
(Dr Bogle) From the health point of view and from monitoring the clinical input and activity point of view, one would expect the clinical governance lead at the primary care trust to watch the clinical capabilities and aptitude of the professionals in the patch.
(Dr Bogle) That could be better, I believe, by allowing more time for it to happen. It could be better if you had fewer clearer targets and particularly from our point of view as doctors those where we see benefit to patient care and something like the national service frameworks for coronary heart disease where there are targets for the provision of drugs, for the care of patients, and the life expectancy and morbidity in that particular group has shifted significantly, so professionals would like to see targets that are fewer but by which they can easily measure clinically the improvement. The main thing in the Health Service would be the monitoring by the special health authority - of course are new bodies - and the business plan of the primary care trust.
(Mr Hart) First the school itself. You have to remember that this whole target setting agenda is not being discussed in isolation. We have a performance management system which now every school has. Every school has a performance management policy. Every school has a performance related pay system, of which academic targets and other targets will to a greater or lesser extent form part. The information which is generated by the performance management system, by the target setting approach, primarily in my view should be for the benefit of the professionals in the school to inform them as to what action they should be taking to improve the standards of education for individual pupils. Target setting for individual pupils, by the way, is absolutely first class; it is absolutely essential. You even start your target setting for individual pupils if you are moving it up. It is vital information for the school and for the people working in the school. It is vital information for the governing body upon which the parents will be represented because the governing body has to make decisions about the performance related pay of the headteacher and the headteacher makes a recommendation to the Government about the performance related pay of other members of the staff. I think it is very important that the information does go to the local authority as to how the school is performing against targets because the local authority has a strategic role to play and is required to monitor, and if it does not do its job properly it is going to be sat upon by Government or by the Audit Commission and so on. I think that the results should be fed through to central Government. In Wales it is bottom up. In Wales the schools set their own targets. The targets they set then pass through to the local authority who pass them through to the Welsh Assembly, so the information is not secret. That is in my view the order of priority.
(Dr Bogle) I believe that patients should be the ones who are the first call on the targets, the first ones that targets should be there to help, first, in providing information about the services that are available and, getting more sophisticated if you like, the safety and the comparisons between different areas, the sort of thing we were talking about originally, and also targets that would benefit patient care. Another example of that would be coronary heart disease. Patients are the first call on benefiting from targets in my view, or should be. The second group is the professionals and the managers working in the field and really as a management tool to see how you are doing against set objectives. That is why it is important that the set objectives are basically decided locally and have some meaning and some ownership from the people using them. Last, but certainly not least, fitting in with what David said, the Government should be getting the aggregated information with their responsibility for providing health services.
(Dr Bogle) I believe that is happening, yes.
(Dr Bogle) Yes. The more targets there are the worse it is getting. Ticking a box and saying that you have achieved a certain level of waiting time or ambulance response is not the point. The idea is that you should be benefiting patient care.
(Dr Bogle) No, it is not happening in reality. What we were trying to say in our memorandum was what we thought should happen and where targets could help. That was the purpose of that and I believe what the consultants were saying was that they, as much as anybody, voting according only to targets, would mean that we wanted targets to show benefit to patient care, obviously. I have no doubt that the answer to your original question is that in the Health Service the patient should be the one who will get benefit from the setting of targets.
(Mr Hart) Eventually, if it goes on year after year, they will be removed. That is a fact of life. They will be removed but it has to take place over a reasonably lengthy period of time because -----
(Mr Hart) I will tell you why. The problem we have got at the moment is that people assume that as night follows day your results must go up year after year; they must go up irrespective of the fact that you can get a different profile of pupils coming into your school which may well hit the results. We have got to get away from what I think is excessive accountability. I believe in accountability but I think this is excessive accountability. We have to allow for hiccups. There will be hiccups in results. That is a fact of life. Obviously, if a school has made a professional judgment as to what its targets should be and it falls short of its own targets, then serious questions will be raised, and if there is no good reason for falling short of targets which can be explained as a result of factors in year, for instance, you can get refugee children coming in in the middle of the year or something of that nature which can distort the picture, then serious questions will be raised. If that goes on, say, over a period of three years or so, then I think the head will be at risk. Certainly the head will not a get a performance related pay aware in the first year, that is for sure.
(Mr Hart) You could do, but if the professional responsibility is allowed to lie with the school to decide its own targets, and it will decide that upon an aggregation based upon the individual pupil targets and then move them through the departments and the faculties and so on, then it is signed up to a target which it believes it can achieve at the end of the day. If there are good reasons why that target is missed then those reasons should be acceptable to the governing body and to the local authority that is monitoring the situation. If there is no good reason for that target to be missed then questions will be asked. All I am saying is that there will be in-year reasons why the target has been missed. If there are no in-year reasons for that then serious questions will be asked and that is accountability. That is what I am perfectly happy to sign up for.
(Dr Bogle) In general not in the Health Service. I am trying to think of one where the shelf life might have expired but no is the answer I will give to that.
(Mr Hart) I guess, for instance, if you are going to have targets for truancy reduction or for attendance improvement, those targets might have a shelf life if we do achieve an improvement on the truancy situation and the attendance situation, but the academic targets certainly will not have a shelf life. They will be with us ad nauseam, I guess. I do not say that, by the way, negatively. I think they will be with us ad nauseam because they are key targets.
(Dr Bogle) Yes, but there is a contradiction between total efficiency and 100 per cent bed occupancy and patient choice because a lot of patients choose to go somewhere where there is 100 per cent bed occupancy. I believe that the Government are right to increase patient choice. One of the things that I would like to go back into practice again would be to have this choice of multiple providers that is now being offered, not just to be stuck with your local district general hospital but to have other choices, but you do need to free up some slack in the system. I know you have also had our A&E report which refers to the bed occupancy and even within a hospital unit, if you operate 100 per cent bed occupancy, you block your A&E. The idea of patients being able to go wherever is at the moment more theoretical, but I still think it is something we should be aiming for because it is a choice patients should have.
(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.
(Mr Hart) Absolutely. In London, for instance, the situation about the provisions is chaotic.
(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.
(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.
(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.
(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
(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.
(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.
(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.
(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.
(Dr Bogle) I did promise that I would produce more. The memorandum was obviously without the advantage of all the other paperwork.
(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."
(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.
(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.
(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.
(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.
(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.
(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.
(Dr Bogle) It will spur me into performance in areas where I know there is a minimum amount of risk.
(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?
(Dr Bogle) Yes. It is not the best day for the BMA. On the other hand, if you do go out to an open ballot, occasionally you get a result that maybe was not quite what was expected. That is why I need to get back and assist in dealing with it.
(Dr Bogle) Life is not like that. It might be all surgeons deciding to just do simpler operations and nobody at all copes with the other ones. It is just a question of looking into all statistics and saying why is your rate worse than others. That is all I would ask for: listen to the reasoning before you make a judgment.
(Dr Bogle) I believe the profession wants to work in a health service that has increased investment, gives better service to patients and they wish to retain or regain some clinical freedom in the consulting room as to the way they deal with their patients. There are vast areas between the government and ourselves where there is agreement. We have focused on targets setting. That is your remit. I have set views, but there is a raft of other things that we are talking about with the government where there is agreement. I would ask you not to take such a pessimistic view either of the future or of the BMA's contribution.
(Mr Hart) In the education service, the danger is that schools will simply get on with the job, as they have always done, of sorting their own targets out, challenging the achievable at school level and will increasingly ignore what teh local authorities may have signed up to with central government and will say, "Fine, if the Chancellor wants to enter into PSAs and the departments want to sign up to them and those are the targets, so be it." At the end of the day, the ministers will be accountable to you. Perhaps they should be more accountable to you in terms of progress against these targets across the board and the electorate will decide at the next election as to whether the government has or has not achieved its aspirations in educational terms. It will not damage the relationship between heads and central government to the degree you think it will because that is a good relationship and I think it will continue to be. We will always have these odd squalls which we will have to try and sort out. This is an issue which does disturb head teachers a great deal because of the impact it has on them in terms of running their schools and relationships with local authorities, but maybe we will have to agree to disagree. The government can have its targets and we will do our very best to try and make sure those targets are met.
(Mr Hart) Because the government simply cannot macro manage 24,000 schools. Otherwise it would get rid of local education authorities tomorrow. It has to have local authorities for all sorts of good, strategic reasons. It has to rely on the local authorities to deliver its agenda. The problem we have at the moment is that the government tends to want to both steer and row the boat. It can steer the boat, if it wants to, if we row the boat. We have to respect our roles. I am absolutely certain we will improve results across the spectrum. Whether we will achieve the 85 per cent that the government wants us to achieve by 2004 remains to be seen. It will not be for want of trying. We will not stop trying because we do not necessarily agree with the targets, but it would be nice if we could get some consensus around how that agenda lives with our common belief that there should be more autonomy and more respect for the professionalism and judgment of teachers.
(Dr Bogle) I have not a clue. 75 per cent in a ballot is quite a high turn out. I would have hoped it was not disinterest because it is something that affects their future in a big way, but I do not know.
(Dr Bogle) We could look down telescopes at election turn outs.
Chairman: I think more work in the office when you get back! May I thank you both very much? It may be unusual for you to come together to talk in this way about services but it is very valuable for us both in what you have said and in the memorandum that you have given us. You are both distinguished leaders in your professions and we are very grateful to you for all the help that you were able to give us. Thank you very much.