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Mr. Norman: Does the Minister accept that the case made by the hon. Member for Wyre Forest (Dr. Taylor) and many others, including the Royal College of Physicians and the BMA, is not that the working time directive is a bad idea of itself but that the NHS is simply not prepared for its implementation? It is common sense to say that there is every case for deferring implementation so that hospitals, and especially smaller units, are allowed more time to prepare for it. If the Minister does not accept that, will he guarantee that not one single acute bed will be lost and that not one single acute unit will close at night as a consequence of implementation in August 2004?
Dr. Ladyman: The guarantee of not losing a single bed or a single service is unreasonable. Services will certainly change. However, it would be our objective to strive to meet that guarantee. I expect to give the hon. Gentleman an idea of how we intend to achieve that and I hope that he will be in a better position to judge whether the NHS will be prepared in time.
As I said, the issue is not simply about junior doctors: it is about different and better ways of working across all professional groups, and redesigning services so that we do not need to reconfigure them. That means approaching planning for reducing the hours that doctors in training work from a different perspective, especially in dealing with acute services out of hours. Our hospital at night pilot sites are developing some interesting models. For example, rather than maintaining multiple rotas across all the specialties at night, a single, multidisciplinary team is put together to cover the whole hospital, or at least a large part of it, for the out-of-hours period. The composition of the team is determined by analysing what actually happens during the out-of-hours period and, from that, defining what skills are needed within the team to ensure safe, high-quality services at all times. That is the sort of reconfiguration and redesign of working practice of which the hon. Member for Tunbridge Wells (Mr. Norman) is no doubt aware from his experiences outside the House. It shows the effort that we need to make in the NHS.
In respect of maternity services and the care of the new born, paediatrics and obstetrics are two acute specialties that do not easily lend themselves to cross-cover. We are funding national pilot sites concerned specifically with those services. We recognise that they require particular and different solutions from those needed for general acute services. I am delighted that Professor Bill Dunlop, president of the Royal College of Obstetricians and Gynaecologists and chairman of the joint consultants committee, is chairing a working party to consider the issues and possible solutions further.
Some solutions that we are considering specifically to keep services local include increasing the supply of staff and exploring skill-mix, but that will, of course, need to be considered in light of the national service framework for children, which will cover maternity services. Other options available for consideration will include innovative models of maternal and neonatal care, including the scope for extending midwife-led care and the potential for midwives to enhance their roles. The Department has also invested centrally in the growth of both paediatrics and obstetrics and gynaecology specialties. As a result, the number of trainees increased by about 27 per cent. for paediatrics and 10 per cent. for obstetrics and gynaecology between 1997 and 2002.
So far as smaller hospitals are concerned, reconfiguration and implementation of the directive need not mean closure of local hospitals. When combined with the potential of redesign, and considering the whole health system in the locality, models of care can be developed that enable all the hospitals in an area to work together to provide the full range of services for local people. There will need to be significant changes to ways of working, including much greater use of non-medical practitioners and increasing use of emergency teams to provide cover at night. That is why we are encouraging and funding the piloting of innovative service delivery models that have the potential to improve sustainability of services, especially in smaller hospitals. That includes working with health systems to plan change and build on the evidence base to support the concepts and service models described in
"Keeping the NHS Local—A New Direction of Travel", which I was delighted to hear the hon. Member for Wyre Forest describe as a splendid document.Importantly, that strategy means that the NHS needs to develop options for change with, rather than for, patients and local people, another point made by the hon. Gentleman. That does not mean, however, that local hospitals will never change. There will be times when there is strong evidence to support the centralisation of some specialised care into larger centres to give patients the best possible outcomes. Equally, there will be opportunities to move services out of larger centres into more local settings. That is another reason why I cannot give the hon. Member for Tunbridge Wells the guarantee that he sought because there will be times when it is inevitable that services change.
Our focus is on redesign rather than relocation. Redesigning services extends the options for meeting local needs and expectations. The NHS needs to exploit the contributions of different hospitals and primary, intermediate and social care providers. They need to work in partnership, with genuine integration and joint planning of services. The strategic health authorities are also overseeing that work. In very simple terms, the key to planning for compliance can be described as the three R's: rotas, roles and redesigned services. Many parts of the NHS are already putting that planning into effect.
As well as the hospital at night pilots we have 10 working time directive pilot projects up and running, testing new approaches to service delivery and showing how effective new roles for staff and new ways of working can be. Some of those pilots are looking at doctors' rotas. They are testing the benefits of consultants working at night and of senior house officers cross-covering between medicine and surgery or medicine and accident and emergency. They are testing shift systems for doctors, and rotas that combine SHOs with other practitioners at night and out of hours. Those changes can be challenging, but they can also be rewarding.
Other pilots are testing changes to the traditional roles of non-medical practitioners; there are new roles for nurse practitioners on call to the wards at night. In another pilot, theatre technicians have been given the opportunity to train to work in resuscitation teams. One of the pilots is developing new, non-medical roles in anaesthesia in several trusts around the country, supported by the Modernisation Agency's changing work force programme. In another pilot, nurses, operating department technicians and a physiotherapist are training together as peri-operative specialist practitioners to take on the complete care of patients before and after operations.
Overall, our strategy for reducing the hours that junior doctors in training work is a multi-faceted challenge and one that is underpinned by the safety of patients. Although it is individual NHS trusts that have to find the right solutions for their local circumstances, they can do that only with the right support from their strategic health authorities, from professional organisations and from the Department of Health. So I am pleased to be able to tell the House that all those organisations are indeed working closely together at
national level to ensure that the quality of service is maintained and, where possible, improved during implementation of the directive.I recognise that more must be done to reduce working hours, and that will inevitably mean further investment to support the changes that will be necessary. We have already allocated over £21 million this year to the NHS to prepare for the directive's implementation. Of that, over £7 million has supported the working time directive and hospital at night pilot projects, and a further £12 million is going to SHAs to provide further local support.
Clearly, if we are to succeed in reducing the hours that junior doctors work there will be a need for more doctors, although that is not, and cannot be, the only solution. It is important also that trusts demonstrate that they have considered all the options and not gone straight for the more and more doctors scenario. We must use this opportunity to move away from outdated working practices that are not helpful to doctors in training or, more importantly, the quality of patient care.
On that point, I am proud to say that we have increased significantly the number of consultants in post: their numbers have risen by nearly 7,000 since 1997, an increase of 32 per cent. We will increase the numbers of consultants and GPs by a further 15,000 by 2008 over the 2001 figure. The hon. Member for Wyre Forest acknowledged what we have achieved so far, but said that he wanted the doctors to become available more quickly. We want that too, but they do not grow on trees, and they take time to train. We are producing them as rapidly as we can.
In addition, we have achieved our target of a further 1,000 specialist registrars 18 months ahead of schedule, and that growth is continuing. In 2003–04, we are distributing central funding for the implementation of 400 more training opportunities and we have also given trusts scope to create up to 1,500 additional specialist registrar opportunities through local funding. We have made it clear that those training opportunities should be implemented in a way that supports compliance.
As I stressed earlier, we have made it clear that SHAs must ensure that every trust prepares a fully detailed action plan to achieve compliance. The strategy for achieving that may include additional specialist registrar posts, and opportunities to fund additional posts locally should be targeted to support that. If further national training numbers are needed to support compliance, they will be released on the completion of plans signed off by SHAs in collaboration with postgraduate deaneries.
We must be clear that increases in training numbers should not be a substitute for changing working practices; it is not possible to comply with the directive solely by increasing the number of specialist registrars. To target the limited resource of additional doctors most effectively, it is essential that plans are quality-assured and produced through a robust process, including consultation with neighbouring work force development confederations and postgraduate deaneries where necessary.
Trusts already have the scope to convert SHO posts to specialist registrar posts—up to 700 in surgical specialties and up to 600 in other specialties. WDCs and postgraduate deans are currently working with trusts on SHO conversions, and that should be explored as a strategy to help to achieve compliance, linked to a review of the level of cover needed at different times of the day and night.
In 2003–04, we are distributing central funding for the implementation of 400 more training opportunities, and we have also given trusts scope to create up to 1,500 additional specialist registrar opportunities through local funding. Postgraduate deans are giving priority to hospitals facing working-time directive challenges when considering—
The motion having been made at Ten o' clock, and the debate having continued for half an hour, Mr. Deputy Speaker adjourned the House, without Question put, pursuant to the Standing Order.
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